1901 Ave. I 141 E. Nopal Hondo, TX Uvalde, TX Phone: Phone: Fax: Fax:

Transcription

1 BLUEBONNET CHILDRENS ADVOCACY CENTER TRI-COUNTY CASA APPLICATION FOR EMPLOYMENT 1901 Ave. I 141 E. Nopal Hondo, TX Uvalde, TX Phone: Phone: Fax: Fax: GENERAL INFORMATION Name: Date: Social Security Number: Date of Birth: Address: City State Zip Home Phone: Business Phone: Fax: Address: In case of emergency call: Phone: Marital Status: Name of spouse: Spouse Employer: Bus. Phone: Children s Names: Age: Age: Age: Educational: High School Diploma School Name G.E.D.

2 College Degree Degree College Name EMPLOYMENT HISTORY Starting with present or most recent employer, please list your employment history for the last five years. Include self-employment and summer and part time jobs. If more space is required, please continue on a separate sheet. 1. Employer Name: Employer address: Phone Number: How Long? Part or Full time: In what capacity: 2. Employer Name: Employer address: Phone Number: How Long? Part or Full time: In what capacity: 3. Employer Name: Employer address: Phone Number: How Long? Part or Full time: In what capacity: If additional listings are appropriate please list on a separate page and attach to application. VOLUNTEER INFORMATION Volunteer experiences: Current 1. ( ) 2. ( ) 3. ( ) 4. ( ) If married, how does your spouse feel about your working for the Bluebonnet Children s Center/Tri County CASA? 2

3 Hobbies or other non-work interests: What do you feel are the strengths and weakness that you will bring to this program? (i.e. background in counseling, legal, bilingual, etc.; hindrances such as health, family obligations, limitations on hours available) List any secondary language(s); including signing, you may speak: Have you had a personal experience involving the following? Child Protective Services Probation (Adult) Domestic Violence Drug or Alcohol Issues BACKGROUND INFORMATION Due to the nature of the Bluebonnet Children s Advocacy Center / Tri County CASA volunteer s responsibilities and contacts, a background check of applicants will be conducted by various law enforcement agencies. A criminal background check will be conducted through Choice Point/Volunteer Select Plus and Texas Department of Public Safety to include a local, state and national check. Your information will also be processed with the Texas Department of Family and Protective Services to check for any history with Child Protective Services/ Child Abuse Registry. Your information will also be processed through the National Sex Offender Registry. Bluebonnet Children s Advocacy Center does not accept applicants if they or an immediate family member have been convicted of, or have charges pending for, a felony or misdemeanor involving a sex offense, child abuse or neglect, or related acts that would pose risks to children or to the CASA program s credibility. 3

4 Have you ever been convicted of, charged with, or arrested for any felony of any type or misdemeanor classified as an offense against a person or family, public indecency, or a violation of the Texas Controlled Substances Act? Yes No If yes, please explain Are you under current indictment or has a district/ county attorney accepted an official complaint for any of the above listed offenses? Yes No If yes, please explain Have you ever been accused of inappropriate behavior with a child? Yes No If yes, please explain REFERENCES Please list 3 personal references. At least one reference must be someone other than a friend or co-worker. For example: minister, rabbi, teacher, employer, therapist, etc. References from relatives cannot be accepted. Name: Mr./Ms./Mrs. Address: Zip Phone: Relationship: Name: Mr./Ms./Mrs. Address: Zip Phone: Relationship: Continued from page 5 Name: Mr./Ms./Mrs. Address: Zip Phone: Relationship: DRIVER S LICENSE INFORMATION All volunteers must have a valid driver s license on file with the Executive office. APPLICANT BACKGROUND CHECK ACKNOWLEDGEMENT FORM 4

5 Because of the confidential nature of serving children who have been abused, neglected or abandoned, as a matter of routine, the Bluebonnet Children s Center requires that each prospective board applicant give permission and provide information necessary for the background check to be performed. In order to comply with this requirement, you will be required to sign an authorization for criminal background check (local, state, and national), child abuse registry check, and a national sex offender check. I agree that the Bluebonnet Children s Center may review any information obtained by these background check. I further understand if I do not comply with this procedure and/or the guidelines set forth in the Volunteer Background Check Acknowledgement Form, I will not be able to become a Bluebonnet Children s Center Board member. I hereby acknowledge that I have been informed that the Bluebonnet Children s Advocacy Center is contacting the Texas Department of Family and Protective Services to obtain information on Child Protective Services involvement and Choice Point/Volunteer Select Plus to obtain criminal history information. I understand that any information obtained will be used to aid in determining my qualifications for services as a volunteer for the Bluebonnet Children s Advocacy Center. I understand that the Bluebonnet Children s Advocacy Center reserves the right to reject any volunteer who has been convicted of, charged with, or arrested for any felony of any type or any misdemeanor classified as an offense against a person or family, public indecency, violation of the Texas Controlled Substances Act, or involving violence of any kind. I understand that qualities of a successful board member include interpersonal skills, compassion, punctuality, and reliability. I further understand that if concerns arise the Bluebonnet Children s Advocacy Center Program Director reserves the right to reject an applicant at any time. I understand that all information provided to and obtained by the Bluebonnet Children s Advocacy Center will be held in the strictest of confidence. The Bluebonnet Children s Advocacy Center may, however, disclose to other agencies and organizations, which utilize volunteers, the fact that I applied for and/or served with the Bluebonnet Children s Advocacy Center as a board member. Furthermore, all information obtained by the Bluebonnet Children s Advocacy Center will be deemed to be the sole property of the Agency, and shall not be available to me or anyone outside the Agency. 5

6 Signature Date Printed Name Please return this completed application to the Bluebonnet Children s Advocacy Center at the address on the first page. Allow ten working days for response. Office Use Only: Received: / / Board Review: / / Board Approved / Rejected: / / Signature of Board President: Date: / / 6