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Hall-Dawson Court Appointed Special Advocate

Volunteer Application Form – mail to P.O. Box 907471, Gainesville, GA 30503

Name:________________________________________________________________________________

_{(Last) (First) (Middle) (Name Used)}

Home Address: ________________________________________________________________________

City:__________________________County:___________________State:_________Zip Code:_________

Mailing Address: (If different from above) ____________________________________________________

_____________________________________________________________________________________

Email Address: ________________________________________________________________________

Daytime Phone Number: __________________________________ May you be called at work?_________

Evening Phone Number: _____________________________Cell/Beeper: __________________________

Current Employer: ______________________________________________________________________

Employer Address: _____________________________________________________________________

Length of Employment:______________Position/Occupation: ____________________________________

Marital Status:_____Sex:_____B’day M____D____Spouse’s Name:_______________________________

Children and Ages: _____________________________________________________________________

Have you or anyone in your family ever been involved with the Department of Family and Children Services as a client or referral? ___________________________________________________________________

Have you ever worked for the Department of Family and Children Services?

(Include service as a foster parent) Yes ______ No ______ Foster Parent______ Dates__________

Have you ever worked for the Juvenile Court? Yes _____ No _____ Dates_______________

Have you ever been convicted of any violation of law other than Traffic? Yes_________ No __________

_____________________________________________________________________________________

List any volunteer experience(s) and how long: _______________________________________________

_____________________________________________________________________________________

Have you ever sought treatment for or currently in treatment for mental illness?Yes____No____Dates____

_____________________________________________________________________________________

List any other experiences, education or training related to children and families: _____________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

REFERENCES: Three (3) References (References cannot be relatives):

Complete contact information must be provided on all references

1. Name: _____________________________________________________________________________

Address: _____________________________________________________________________________

City: ______________________________________ State: ____________ Zip Code: ________________

Phone Number: (H)_______________________________ (W)___________________________________

Relationship: __________________________________________________________________________

2. Name: _____________________________________________________________________________

Address: _____________________________________________________________________________

City: _____________________________________ State: ____________ Zip Code: _________________

Phone Number: (H)_______________________________ (W)___________________________________

Relationship: __________________________________________________________________________

3. Name: _____________________________________________________________________________

Address: _____________________________________________________________________________

City: _____________________________________ State: ____________ Zip Code: _________________

Phone Number: (H)______________________________ (W)____________________________________

Relationship: __________________________________________________________________________

A copy of your driver’s license must be included with the application. CASA Volunteers are not allowed to transport clients under any circumstances.

I verify that all the information contained in this application is true and correct to the best of my knowledge.

Signature: ____________________________________________________Date:___________________

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