VOLUNTEER APPLICATION

CASA of Los Angeles Member National Court Appointed Special Advocate Association 201 Centre Plaza Drive Suite 1100 Monterey Park, California 91754 Phone 323-859-2888 Fax 323-264-5020 www.casala.org VOLUNTEER APPLICATION Court Appointed Special Advocate For Office Use: Application received: / / Orientation: / / Interview: / / CONTACT INFORMATION: Full Name: Date of Birth: Home Phone: Cell Phone: E-Mail: Emergency Contact: Relationship: Home Phone: EMPLOYMENT INFORMATION: Unemployed Retired Full Time Part Time Self-Employed Seeking Employment Name of Current Employer, or if Retired or Unemployed, Previous Employer: Hire Date: To: Occupation: Work Phone: May we contact you at work? yes no Describe work experience: 09/17/13 Page 1 of 4

Education: High School (check last year completed) 9 10 11 12 College (check last year completed) 1 2 3 4 Specify area of study/degree: Graduate (check last year completed) 1 2 3 4 Specify area of study/degree: Are you currently attending school? yes no If yes, specify school: Area of study/degree objective: Are you bilingual? yes no If yes, specify language(s): Ethnicity: African American Asian/Pacific Islander Hispanic/Latino Multi-Racial White/Non-Latino Other (specify): Decline to State How did you become aware of the CASA Program? Special skills and/or recreational interests: Describe prior volunteer experience: Have your life experiences included working with people of races and social/economic circumstances different than your own? yes no If yes, please describe: Time availability: CASA of Los Angeles requires a two-year commitment. The time demands for CASA volunteers vary with the case assignment. We estimate volunteers devote an average of 5 hours per week to case activities. Some activities may be completed by telephone. Court appearances and other case activities will require you to be available during the regular workweek hours (i.e. contact with CASA supervisors, social workers, teachers, therapists, etc.). Court hearings are scheduled in advance and ample notice is given, barring any unforeseen circumstances. Do you have any particular time restrictions? yes no If yes, please explain: Training: Successful completion of all training is required for acceptance into the CASA program. Attendance at all training sessions is mandatory. Can you commit to the training with advance notice? yes no (Many employers allow and encourage employee volunteer service to the community.) Travel: CASA of Los Angeles serves children throughout Los Angeles County. Traveling is necessary as the duties of a Court Appointed Special Advocate include monthly, face-to-face contact with a child wherever the child is residing. Traveling may also be necessary for interviews or conferences with other parties related to the case or to conduct on-site assessments. Liability: All volunteers are required to maintain automobile liability coverage, which satisfies the requirements under California law. Note: CASA of Los Angeles requires annual verification of automobile insurance and valid California Driver s License. 09/17/13 Page 2 of 4

Security Clearance: Please read and complete the security clearance form and return attached to this application. All applicants accepted for training will be fingerprinted for a background check conducted by the Los Angeles Superior Court. Have you ever been: Arrested for a crime against a child? yes no Arrested for a violent felony? yes no Arrested for a sex crime? yes no Health Background: CASA volunteers deal with sensitive issues that may be emotionally demanding. For this reason, the following questions are asked with the understanding that all information is confidential. 1. Do you have any physical limitations? yes no If yes, please describe. 2. Do you take any medications? yes no 3. Have you ever participated in counseling or psychotherapy? yes no 4. Do you have personal experience with issues related to any of the following: a. Child abuse yes no b. Domestic violence yes no c. Substance abuse yes no 5. Have you ever been prescribed any medications for mental health issues? yes no Personal Statement: Please submit a typed response to the following questions and attach the sheet to this application. 1. Describe your childhood. 2. State any personal or professional experiences you have had concerning issues of physical, sexual and/or emotional abuse or neglect or abandonment of children. 3. State any personal or professional experiences you have had concerning issues of domestic violence and/or substance abuse. 4. Why would you like to become a CASA volunteer? 5. How do you hope to benefit from this experience? 6. Have you or anyone you know ever been involved in a dependency court proceeding involving a child in the foster care system? yes no If yes, please explain. References: Please list three non-relative references who have known you for at least 2 years and can describe your personal and/or professional capacity to work as a volunteer with CASA. At least one reference should be from employment or volunteer experiences. These references will be contacted and asked to complete a reference questionnaire. All references are confidential. 1. Name: Relationship: Email: Phone: 2. Name: Relationship: Email: Phone: 3. Name: Relationship: Email: Phone: 09/17/13 Page 3 of 4

AGREEMENT (Please initial where indicated.) As a potential CASA volunteer, I understand that I must meet the following preliminary qualifications: 1. I am over 21 years of age. 2. I do not have any criminal convictions. 3. I own a personal vehicle and am willing to drive in my capacity as a CASA volunteer. 4. I am not a foster parent nor do I receive financial compensation from DCFS or any DCFS contractor. 5. Upon successful completion of the screening and volunteer training, I will be expected to serve approximately 20 hours a month for at least 24 months as a Court Appointed Special Advocate. 6. As an applicant to be a CASA volunteer, I agree to: a) Submit to an investigation of suitability as a CASA, including but not limited to, being fingerprinted, criminal background check (FBI and Department of Justice), and Department of Motor Vehicles records check and/or provide CASA with a copy of your current driver s license, DMV printout and auto insurance annually. b) Participate in on-going supervision and continuing education training classes, cooperating fully with staff and adhering to all agency-approved report-writing criteria. As an applicant of CASA of Los Angeles I understand and acknowledge that CASA of Los Angeles is not obligated in any way to accept me into the volunteer training program by submission of this application. I understand that CASA of Los Angeles retains the right to refuse any individual they feel would not act in a way that would serve the best interests of the child. CASA of Los Angeles is not required to state the reason for declining an applicant into the program if they so choose. I understand that any applicant found to have been convicted of or having current charges pending for a felony or misdemeanor involving a sex offense, child abuse, or child neglect must not be accepted as a CASA volunteer. Signature of Applicant: Date: Please review your application personal statement, and security clearance for completeness and return all ORIGINAL SIGNED forms to: CASA of Los Angeles Edmund D. Edelman Children's Court 201 Centre Plaza Drive, Suite 1100 Monterey Park, CA 91754-2142 09/17/13 Page 4 of 4

SUPERIOR COURT OF CALIFORNIA, COUNTY OF LOS ANGELES SECURITY CLEARANCE CASA PRINT NAME: (Last) (First) (M.I.) Other Names Used: (Last) (First) (M.I.) Driver's License No.: Expiration: DOB: CA I.D. No.: Expiration: SSN: Proper conduct by Court employees inspires public confidence and trust in the Court and conveys the values of impartiality, equality, and fairness that brings integrity to the Court's work. Court employees are expected to demonstrate, through both words and actions, the highest level of personal integrity and honesty in all professional and personal dealings. Employees are also to refrain from any perceived or actual impropriety including violating the law. The Court conducts criminal background checks on candidates to whom it makes offers of employment. Existence of a criminal record is not an automatic bar to employment. In evaluating an applicant's suitability for Court employment, the Court will consider such factors as the nature and recency of the offense(s), the number of offenses and any mitigating circumstances. Full and complete responses to the questions below are required and will be carefully evaluated and verified. Employees' fingerprints are sent to State and Federal agencies for a check of criminal record history. Any false statement or omission of a material fact will cause forfeiture of all rights to employment. ARREST AND CONVICTION INFORMATION Pursuant to California Labor Code section 432.7, the Court, as a criminal justice agency, may inquire about arrests including those that did not result in convictions. 1. Have you ever been convicted of an offense(s) in any criminal or military court or has a juvenile court petition(s) ever been filed against you and found true? Please mark the appropriate box below and, if "Yes", please explain in the chart below. Note: Exclude any offense(s) which resulted in the successful completion of a deferred entry of judgment program(s) (pre-trial diversion) or any offense(s) where court record has been sealed. Security Clearance (Revised April 2007) Page 1 of 3

2. Are you currently being charged, or have you ever been charged, for any violation(s) of law other than minor traffic violations - examples of a minor traffic violation include driving without a license or with a suspended license, speeding, failing to signal, etc.? Please note that "driving under the influence" and "reckless driving" are not minor violations. Please mark the appropriate box below and, if "Yes", please explain in the chart below. 3. Have you ever been arrested or detained by any law enforcement agency or military authority including any arrests while a juvenile? Please mark the appropriate box below and, if "Yes", please explain in the chart below. Note: Exclude any arrests which resulted in the successful completion of a deferred entry of judgment program(s) (pretrial diversion) or any arrests where the records have been sealed. If the response to Question 1,2 and/or 3 is "Yes", provide the information requested below (attach additional sheets if necessary using the same format). Date Offense & Location (City/State) Disposition 4. As an adult, has a warrant(s) ever been issued for your arrest? Please mark the appropriate box below and, if "Yes", please explain in the chart below. Include date(s), reason(s), and disposition of warrant(s). Note: Exclude warrants which resulted in the successful completion of a deferred entry of judgment program(s) (pre-trial diversion). Date Reason Disposition Security Clearance (Revised April 2007) Page 2 of 3

Separation from Employment under Unfavorable Circumstances 5. While on probation or on a similar type of on-the-job trial period, were you ever terminated, discharged, released, or did you resign? Mark the appropriate box below. 6. Have you ever been terminated from any employment, or did you resign while you were under investigation, or after being informed discipline would be taken, or under any other unfavorable circumstances? Mark the appropriate box below. If the response to Question 5 and/or 6 is "Yes", provide the requested information below (attach additional sheets if necessary using the same format). Date Employer Reason for Discharge/Resignation and/or Failure of Probation I certify that the above information is true and correct and that I have not misrepresented my qualifications and/or background. I understand and agree that any false statement or omission of a material fact will cause forfeiture of all rights to employment or participation as a contractor or volunteer with the Superior Court of California, County of Los Angeles. SIGNATURE: DATE: FOR HUMAN RESOURCES USE ONLY Comments: Received by: Date: Security Clearance (Revised April 2007) Page 3 of 3

Please review the following checklist to make sure your application is complete, so that your application can be processed immediately: Did you Address all Personal Statement questions thoroughly? Provide three references with emails on page 3? Initial ALL statements on page 4? Sign and date page 4? And on the Superior Court Security Clearance, did you Include your social security number (SSN) on page 1? Include your Driver s License # and Expiration on page 1? Sign and date page 3? Please submit all ORIGINAL SIGNED forms either in person or by post to: CASA of Los Angeles Edmund D. Edelman Children s Court 201 Centre Plaza Drive, Suite 1100 Monterey Park, CA 91754-2142