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Serving Leavenworth and Atchison Counties
Notice of Screening Procedures
In order to protect children and provide the court with qualified volunteers, a fingerprint-based national criminal history record investigation will be conducted on every applicant, as well as screening through the Department for Children and Families (DCF) Child Abuse and Neglect Central Registry.
The Office of Judicial Administration will submit the applicant's fingerprints to Kansas Bureau of Investigation (KBI) for a Criminal History Record Inquiry. The KBI will provide a report on the applicant's criminal record investigation to the Office of Judicial Administration. Applicants found to have been convicted of, or charges pending for, a felony or misdemeanor involving sex offense, child abuse or neglect, or related acts that would pose risks to children or the CASA program's credibility will not be approved for service. Applicants who do not provide fingerprints for criminal history background checks will not be approved to serve as a CASA.
The applicant's local CASA program will make inquiries to the Department for Children and Families (DCF) Child Abuse and Neglect Central Registry and registries of other states where the applicant has lived in the past five years. If it is found that DCF or a similar agency in another state lists the applicant as the perpetrator of an act of child abuse or neglect the CASA program will generally disallow certification.
All information will be held in strict confidence. Criteria used in the selection of a volunteer will be such as to ensure that the individual is able to meet the responsibilities of a CASA. NO INDIVIDUAL WILL BE REJECTED BECAUSE OF RACE, COLOR, RELIGOUS CREED, NATIONAL ORIGIN, ANCESTRY, GENDER, AGE, DISABILITY, OR MARITAL STATUS.
I have read and agree to the above and certify that the information contained in the CASA Volunteer Application is correct and accurate to the best of my knowledge.
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Indicates required field
Name
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First
Last
Date (MM/DD/YYYY)
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Applicant Information
Full Legal Name
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Preferred Name
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Date of Birth MM/DD/YYYY
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Cell Phone
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Home Phone
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Work Phone
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May you be called at work?
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Yes
No
Address
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Line 1
Line 2
City
State
Zip Code
Country
County of Residence
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Email Address
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Do you have access to a vehicle?
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Yes
No
Maybe
Driver's License #
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Are you a citizen of the United States
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Yes
No
Lawful Permanent Resident?
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Yes
No
How did you hear about CASA?
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?
Kansas CASA Website
Local CASA Website
National CASA Website
Google Search
Facebook or other Social Media
Other Web (online ad, volunteer recruiting website, etc.)
Radio
Billboard
Newspaper (print)
Television
Speech/Presentation in community
Flyer/Brochure
Word of Mouth/personal referral
Other
Work History
Present Employer/Volunteer Supervisor
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Job Title
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Phone Number
*
Dates of Employment MM/YYYY-MM/YYYY
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Previous Employer/Volunteer Supervisor
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Address
*
Line 1
Line 2
City
State
Zip Code
Country
Job Title
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Phone Number
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Dates of Employment MM/YYYY-MM/YYYY
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Previous Employer/Volunteer Supervisor
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Address
*
Line 1
Line 2
City
State
Zip Code
Country
Job Title
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Phone Number
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Dates of Employment MM/YYYY-MM/YYYY
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Education/Training
Highest Level of Education Completed
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Some High School
High School Diploma/GED
Some College
Associates
Bachelors
Masters
Doctor
Other educational/ training programs completed?
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Do you have work Experience and/or training in any of the following areas?
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Art/Graphics
Child Care
Child Development
Counseling
Psychology
Juvenile Court
Health Care
Law Enforcement
Mental Health
Choose Any
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News/Media
Public Speaking
Foreign Languages
Criminology
Drug/Alcohol Abuse
Education
Writing
Social Work
Working with Children
If yes to any of the above, please describe:
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Legal History
It is important that you be thorough and honest in giving of these answers. Answers which are found to be untrue may disqualify you as a potential volunteer.
Have you ever been arrested and/or charged with a crime?
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Yes
No
Have you ever been convicted of a crime?
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Yes
No
Have you ever been placed on a diversion?
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Yes
No
Have you ever had a conviction, adult or juvenile, expunged from your record?
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Yes
No
Have you ever been involved in a juvenile case as an adult or a child?
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Yes
No
Have you ever been the subject of a child abuse/neglect investigation?
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Yes
No
Do you have any experience with child abuse/neglect?
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Yes
No
If you answered YES to any questions, please explain:
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Emergency Contact
Name
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First
Last
Phone Number
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Relationship
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Personal References
Please print names, addresses, and phone numbers of people who have known you for at least two (2) years, who know you well, can address how you relate to children and others, and how well you could fulfill the responsibilities of a CASA. The CASA program staff will contact the references you list.
DO NOT INCLUDE RELATIVES.
Name (Reference 1)
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First
Last
Relationship
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Phone Number
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Address
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Line 1
Line 2
City
State
Zip Code
Country
Length of Acquaintance
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Email
*
Name (Reference 2)
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First
Last
Relationship
*
Phone Number
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Address
*
Line 1
Line 2
City
State
Zip Code
Country
Length of Acquaintance
*
Email
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Name (Reference 3)
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First
Last
Relationship
*
Phone Number
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Address
*
Line 1
Line 2
City
State
Zip Code
Country
Length of Acquaintance
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Email
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