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2. 
4. Name (First, MI, Last)
5. Home Phone
7. Complete Mailing Address
8. State
9. Zip Code
11. Cell Phone
12. Email
13. DOB
15. Occupation
16. Employer
17. How Long? (Years/Months)
19. Work Phone
20. May we contact you at your work number?

    1. Yes
    2. No
21. Work Schedule
23. Do you own an automobile?

    1. Yes
    2. No
24. Is this automobile insurred?

    1. Yes
    2. No
26. Name, relationship and phone number of Emergency Contact
30. EMPLOYMENT HISTORY

    Agency                                                                                            City/State                                                         Start/End Dates

32. 1.
34. 2.
36. 3.
40. Education
42. Highest grade completed
43. Degree Earned
45. Currently Enrolled?

    1. Yes
    2. No
46. Name of School
47. Area of Study
51. VOLUNTEER EXPERIENCE

    Agency                                                                                          City/State                                                              Start/End Dates

53. 1.
55. 2.
59. PERSONAL REFERENCES

    Please list four references. Include an employer/supervisor, if applicable, and at least two people who have known you two years or longer, who are not relatives.

    MUST INCLUDE COMPLETE MAILING ADDRESS - NO PHONE NUMBERS.

    References will be contacted by mail.

    Name                                                                                  Address/City/State/Zip                                                                                    Relationship

61. 1.
63. 2.
65. 3.
67. 4.
71. List personal interests, hobbies, etc.
73. How did you hear about this volunteer opportunity?
77. CRIMINAL, COURT, AND PERSONAL HISTORY
79. Have you ever been convicted of any crime?

    1. Yes
    2. No

    If "yes", list offenses and dates as well as location of offenses.

81. Offense
82. Date
    Date
83. Location
85. Offense
86. Date
    Date
87. Location
89. Offense
90. Date
    Date
91. Location
93. Please explain if you answer "yes" to the following questions:
95. 1. Have you or a family member been involved with any Juvenile Court proceeding?

    1. Yes
    2. No
97. 2. Have you or a family member been involved with Child Protective Services?

    1. Yes
    2. No
99. 3. Are you currently on probation or parole?

    1. Yes
    2. No
101. 4. Have you had your name placed on a registry of child or adult abuse in this or any state?

     1. Yes
     2. No
103. 5. Have you been denied a license to care for children or adults?

     1. Yes
     2. No
105. 6. Have you had a license to care for children or adults suspended or revoked?

     1. Yes
     2. No
107. 7. Do you have any condition or disability which would affect your ability to perform this volunteer work?

     1. Yes
     2. No
109. 8. Has any Court or Disciplinary Board ever found that you have sexually assaulted, exploited, or physically abused any person, adult or child?

     1. Yes
     2. No
111. Explanation to "yes" answers, if any, including criminal and/or CPS history:
115. TO BETTER ASSIST US IN DETERMINING YOUR SUITABILITY, MOTIVATION AND COMMITMENT TO BECOMING A VOLUNTEER, PLEASE RESPOND TO THE FOLLOWING QUESTIONS.
117. 1. Why do you want to become a CASA/GAL Volunteer?
119. 2. What do you feel may be your primary roles as a CASA/GAL Volunteer?
121. 3. Identify your personal qualities that you feel would contribute to the role of a CASA, or that may be a hinderance in the role.
123. 4. Describe any attitudes from your own background, experiences, or knowledge that may prevent you from maintaining an objective perspective on a particular case, e.g., childhood abuse, a parent’s drinking problem, your first response to child abuse is to criticize the parent, or personal values make certain situations intolerable for you.
125. 5. Briefly discuss those factors which you believe cause parents to abuse/neglect their children.
127. I understand that by submitting this application, I authorize inquiries to be made concerning my suitability as a volunteer. The information requested in this application, and such as may otherwise be obtained, will be used only for the purpose of determining suitability as a volunteer. All information will be held in confidence. I authorize you to request and receive such information and I release from all liability any persons supplying it. I also release you from all liability which may result from making the investigation. I understand that Spokane County Juvenile Court may request and receive information from federal and/or state law enforcement agencies, as well as child welfare agencies. I acknowledge and agree that I am not obligated, if called upon, to perform volunteer services for the agency, and the agency is not obligated to assign volunteer service. I declare that the foregoing facts and information contained herein are true and complete to the best of my knowledge. I understand that any falsification, misrepresentation or omission, as well as any misleading statements or omissions, may serve as the basis for a finding of unsuitability as a volunteer, or immediate terminations, regardless of when or how discovered.
129. Electronic Signature Agreement*

     By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

     1. I agree.
131. Electronic Signature*
Leave This Blank:


133. 1. Receive an email copy of this form.
134. Email address

     This field is not part of the form submission.

135. Submit

* indicates a required field