CASA Volunteer Application

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Montgomery County Juvenile Court - Court Appointed Special Advocate Volunteer Application

First Name*
Middle Name
Last Name*
Preferred Nickname
Date of Birth*
Address*
City*
State*
Zip Code*
Have you lived in another state in the past 5 years?*
If yes, please provide previous addresses during that time.
- Yes
- No
Previous Addresses
If yes, please list all previous addresses.
Primary Phone Number*
Work Phone Number
Mobile/Other Phone Number
Email*
Work Email
Emergency Contact Name*
First Last
Emergency Contact Phone*
Relationship (Emergency Contact)*
Employment Status
- Full Time
- Part Time
- Retired
- Not Employed
- Student
Employed By
Job Title
How Long Have You Worked There?
Typical Work Hours
May We Contact You At Work?
- Yes
- No
May We E-Mail You At Work?
- Yes
- No
Do you have flexibility with your day time work hours?
- Yes
- No
Do you have a valid Ohio Driver's License?*
- Yes
- No
Are you willing to travel locally to make contacts and obtain information?*
- Yes
- No
Have you been or are you currently a foster parent?*
- Yes
- No
If yes, with what Agency?
Name, County, State
Do you have a prior history with any Child Protect Services Agency?*
- Yes
- No
If yes, please list offense, nature of offense and dates of each offense.
Have you ever been involved with the Juvenile Justice System?*
- Yes
- No
If yes, please describe involvement.
Have you applied to, or been involved with, another CASA/GAL program in Ohio or another state or U.S. territory?*
- Yes
- No
If yes, which programs?
Describe any volunteer or employment experience you have had working with children.*
Have you ever been convicted of a crime related to children involving violence?*
- Yes
- No
If Yes, please describe involvement.
Ethnicity*
Statistical information required for grant purposes and to assist in matching a child's needs.
- African-American
- Asian-American
- Latino
- Caucasian
- Native American
- Other
- Unknown
Education*
Statistical information required for grant purposes and to assist in matching a child's needs.
- High School Graduate
- GED
- College Graduate
- Some College
- Post Graduate Degree
Primary Language*
- English
- Spanish
- French
- Sign Language
- Other
Secondary Language
- English
- Spanish
- French
- Sign Language
- Other
Please describe in at least 100 words why you would like to be a CASA volunteer?
References
*REQUIRED. Please provide three references. Use professional or personal references only, do not use relatives. Please alert references that we will be contacting them soon, and a prompt reply would be appreciated.
List of References
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Address

380 West Second St.
Dayton, OH 45422

Phone Number

(937) 496-7908

Hours of Operation

Weekdays: 8:30AM–4:30PM
Weekends: CLOSED

CASA Volunteer Application

References

Address

Phone Number

Hours of Operation

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