Missouri > Local Circuit Courts > 7th Circuit (Clay County) > Family Court
CASA Volunteer Application - Missouri
| CASA Volunteer Application Form. This is a Missouri form and can be used in Family Court 7th Circuit (Clay County) Local Circuit Courts . |
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CLAY COUNTY FAMILY COURT CASA VOLUNTEER APPLICATION (Print out app and mail to: CASA - 351 E. Kansas, Liberty MO 64068) Name: __________________________________________________________________ (last) (first) (middle) (maiden) Address: ________________________________________________________________ If less than 3 years your previous address ________________________________________________________________________ Home phone: __________________________ Work phone: ______________________ Pager or Cell Phone_______________________ May we contact you at work? ______ Employment (Present and/or last position) Employer: _______________________________________________________________ Address:________________________________________________________________ (street) (city) (state) (zip) Phone: ___________________ Dates Employed: from_________ to____________ Position held: ______________________ Supervisor: ___________________________ Briefly list your job responsibilities: __________________________________________ ______________________________________________________________________________ __________________________________________________________________ Volunteer Experiences Organization: ____________________________________________________________ Address: ________________________________________________________________ Phone Number: _______________________ Supervisor: ________________________ <<<<<<<<<********>>>>>>>>>>>>> 2 Briefly describe a rewarding experience you had during the time that you volunteered for this organization: _________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ Organization: ____________________________________________________________ Address: ________________________________________________________________ (city) (state) (zip) Phone Number: _______________________ Supervisor: _______________________ Briefly describe a rewarding experience you had during the time that you volunteered for this organization:_________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ Special Skills Describe the skills, talents, and/or special training you possess that you believe would be an asset to the CASA Program: _____________________________________________ _______________________________________________________________________ _______________________________________________________________________ Brief Questions About Yourself Can you make a commitment to this Program for at least one year? If no, please explain: ______________________________________________________ Do you have the following? Your own transportation: ____________ Liability Insurance: _____________________ Valid Drivers License: ____________________________________________________ What is your highest level of education? _______________________________________ What are some your Hobbies/Interests? _______________________________________ How did you hear about the Clay County CASA Program? ____________________ <<<<<<<<<********>>>>>>>>>>>>> 3 Would you like us to keep your employer abreast of your volunteer service and achievement? Yes No Personal References Please list two (2) professional and/or personal (not including relatives) references with complete address and phone number. (REFERENCES WILL REMAIN CONFIDENTAL) # 1 - Name: _____________________________________________________________ Address: _______________________________________________________________ Phone Number: _______________________ Relationship: ______________________ # 2 - Name: ______________________________________________________________ Address: _______________________________________________________________ Phone Number: _______________________ Relationship______________________ Is there anything else youd like us to know: ___________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________ I assert that the information contained herein is, to the best of my knowledge, true and correct. I understand falsification herein will render my application void. _______________________________ _____________________________ Signature of Applicant Date <<<<<<<<<********>>>>>>>>>>>>> 4 IN THE CIRCUIT COURT OF CLAY COUNTY, MISSOURI FAMILY COURT DIVISION CLAY COUNTY CASA PROGRAM Permission to Contact References and Complete Background Investigation I hereby give permission to the Clay County CASA PROGRAM to inquire about my qualifications and/or character by: Contacting Personal References named in Volunteer Application Contacting present and/or past employers Contacting present and/or past organizations for which I have performed volunteer services Completing a background check with the Missouri Child Abuse/Neglect Hotline Central Registry Further, I understand that the Clay County CASA Program will complete a background investigation on me through the Clay County Sheriffs Department or other appropriate and necessary law enforcement agency. INFORMATION NEEDED FOR CRIMINAL RECORD INVESTIGATION Last name: ______________________________ First name: ______________________________ Middle Name: ___________________________ Race: __________________________________ Gender: ________________________________ Date of Birth: ____________________________ Social Security #: _________________________ State of Birth: ____________________________ Drivers License #: ________________________ Aliases or other names used (maiden): ______________________________________________ ___________________________ __________________________ Signature of Applicant Date <<<<<<<<<********>>>>>>>>>>>>> 5
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