San Juan CASA Application

Please list any additional employment or personal commitments that may restrict yourtime to the program: *

Please list any Hobbies and/or Special Interests (computer skills, fundraising, childcare experience, etc.): *

Give a brief description of your employment background:*

Give a brief description of your education and training background:*

Please list the reason(s) you are interested in volunteering:*

What do you hope to gain through your volunteer work with Childhaven/CASA?*

Check if you ever personally experienced or worked with any of the following?*

Foster CareJuvenile Court SystemChild CareOther Child Serving Agencies

If so, please explain:*

Working closely with abused and neglected children can be stressful. Describe the types of support available to you:*

Do you have any difficulties with your health that may limit your ability to perform your duties?*

YesNo

If so, please explain:*

How long have you lived in San Juan County*

How long have you lived in New Mexico?*

Do you speak any other language besides English (i.e. Spanish, Navajo, etc.)?*

YesNo

If yes, please list the additional languages you speak.*

Are you able to commit to the volunteer program at the San Juan CASA Program for one year?*

YesNo

Can you commit to attending in-services and supervision required?*

YesNo

Is there anything else you would like to let the San Juan CASA Program know about yourself?*

WE WILL USE THE EMPLOYER LISTED ABOVE AS ONE OF YOUR REFERENCES. PLEASE LIST FOUR ADDITIONAL REFERENCES WE MAY CONTACT, ONE REFERENCE MUST BE A RELATIVE. BE SURE TO GIVE COMPLETE AND CURRENT ADDRESSES AND PHONE NUMBERS.

Reference 1

Name*

First NameLast Name

Relationship*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Number*

Format: (000) 000-0000.

Work/Cell Number*

Format: (000) 000-0000.

Email*

example@example.com

Reference 2

Name*

First NameLast Name

Relationship*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Number*

Format: (000) 000-0000.

Work/Cell Number*

Format: (000) 000-0000.

Email*

example@example.com

Reference 3

Name*

First NameLast Name

Relationship*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Number*

Format: (000) 000-0000.

Work/Cell Number*

Format: (000) 000-0000.

Email*

example@example.com

Reference 4

Name*

First NameLast Name

Relationship*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Number*

Format: (000) 000-0000.

Work/Cell Number*

Format: (000) 000-0000.

Email*

example@example.com

Childhaven is an “Equal Opportunity Employer”. Opportunities for employment, advancement, training and compensation are equal for applicants and employees regardless of race, color, creed, national origin, gender, age, marital status, sexual orientation or disability at all levels of employment.

I understand that Childhaven will conduct background searches to include but not limited to the following: State Court, Sex Offender Registries, State, Local, & Federal Law Enforcement, Motor Vehicle Reports, SSN Verification and the Children, Youth &Family Departments.

Rejection Policy

A CASA volunteer applicant will be rejected if the applicant is found to have been convicted of, or having charges pending for a felony or misdemeanor involving a sex offense, child abuse or neglect, or related acts that would pose risks to a child or the San Juan CASA Program’s credibility

Signature*

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San Juan CASA Application

Employment & Background Information

References