Employment History

Personal Information

Please provide COMPLETE contact information for three non-family references who have known you for at least one year.

Please do not list a relative or significant other. If possible, please list an employer or supervisor.

Reference 1 Information

Reference 2 Information

Reference 3 Information

Please respond to the following:

EQUAL OPPORTUNITY AND ANTI-HARASSMENT STATEMENT – Piedmont CASA prohibits discrimination against, or harassment of, any employee or applicant for employment, or against any volunteer or applicant to serve as a volunteer on the basis of age, color, disability, gender identity or expression, marital status, military status (which includes active duty service members, reserve service members, and dependents), national or ethnic origin, political affiliation, pregnancy (including childbirth and related conditions), race, religion, sex, sexual orientation, veteran status, family medical or genetic information, or any other basis made illegal by the laws of the United States or of the Commonwealth of Virginia.

The following page is for statistical purposes only. Please mark the choice or choices that best describe you.

Piedmont CASA, Inc. Training Agreement

Prospective volunteers are asked to read and sign the following training description and agreement:

Agreement:

1. I understand that participation in the Pre-Service Volunteer Training is required and essential and includes 40 hours of scheduled classroom time.

2. I understand that, in addition to the classroom sessions, I will be required to complete two hours of courtroom observation at one of the Juvenile and Domestic Relations District Courts that CASA serves, as well as writing and reading assignments outside of the classroom.

3. Attendance: I understand that attendance at training is mandatory.

4. I am aware that the Pre-Service Training Class is a part of the screening process and that acceptance to participate in training does not guarantee that I will be sworn in as a CASA or that I will be assigned to a case. I further understand that either Piedmont CASA or I can choose to discontinue my involvement in the training/screening process at any time without further obligation on the part of either party.

5. Upon completion of training, my participation in the training process, as well as other screening material (references, criminal record check, Child Abuse/Neglect Central Registry check and DMV record check) will be reviewed for the purpose of determining my eligibility to be assigned a case as a CASA.

I understand and am willing to meet all the conditions stated above and wish to participate in the CASA Pre-Service Training.

The Undersigned acknowledges and agrees that:

I am interested in becoming a CASA Volunteer and know of no reasons why I should not be assigned to a child in the CASA program. I am aware that the children CASA serves have been abused and/or neglected by adults. I do not want to be another cause of disappointment to a child, and acknowledge that I will make a commitment of at least 14 to 18 months to the child(ren) and case to which I may be assigned.

Piedmont CASA is not obligated in any way to accept me into the volunteer training program by accepting this application, and Piedmont CASA retains the right to refuse any individual. Piedmont CASA is not required to state reason(s) for non-acceptance into the program. Piedmont CASA will hold all information in the volunteer’s file in strictest confidence. Such information becomes the property of Piedmont CASA.

I hereby certify that all statements made on this application are true and correct to the best of my knowledge. I understand that by submitting this application, I authorize inquiries concerning my employment and character for the purpose of determining my suitability as a CASA Volunteer. I further understand that by my signature on this application, I authorize Piedmont CASA to complete national and state record checks of criminal history, Departments of Social Services and Departments of Motor Vehicles in every state or country in which I have resided for the last seven years. I grant Piedmont CASA the authority to follow up on offenses reported and understand that information obtained may preclude me from becoming a Piedmont CASA Volunteer. I understand that conviction or 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 the CASA program’s credibility are grounds to reject my application. All information will be held in strictest confidence. Having considered the opportunities and responsibilities involved, I offer my services as a Court Appointed Special Advocate for the Charlottesville/Albemarle, Louisa and Greene Juvenile and Domestic Relations District Courts and agree to follow all guidelines set forth by Piedmont CASA, Inc. Specifically, I will keep all information and knowledge acquired during my involvement with the program strictly confidential. Criteria used in the selection of Volunteers will be such as to ensure that the individual is able to meet the responsibilities of a Court Appointed Special Advocate.

*CASA Volunteer applications will be rejected if the applicant refuses to sign the appropriate releases of information for criminal, DSS Central Registry and Division of Motor Vehicle record checks.

Piedmont CASA Disclosure Statement and Authorization for Alternate Background Search

For the purpose of my continued service with Piedmont CASA, I authorize Piedmont CASA, Inc. to request a background check report on me. I understand that this check will include, but not be limited to, background checks using:

• National, regional and state database searches (with or without National Sex Offender Registry search included)
• Federal and county courthouse searches
• Department of Motor Vehicles