If you are interested in becoming a CASA of Menominee County Volunteer, please print off the following form, complete it, and mail to:

CASA of Menominee County

P.O. Box 456

Menominee, MI  49858

Last name_______________________________ First name________________________ Middle______________

Home address______________________________________________________________ Apt_________________

City _________________________________________________________ State____________ ZIP __________

County  _____________________________________ Social Security number__________________________

Home phone number____________________________ Work phone number_____________________________

Employment status m Full time      m Part time          m Student  m Not employed      m Retired             m Don’t know

Place of Employment __________________________________________________________________________

Position ______________________________________________________________________________________

E-mail address                                                                                                                                 Fax number                                     

Emergency phone________________________ Emergency contact_____________________________________

Gender  m Female m Male             Date of birth________________________________________________________

Ethnicity         m African-American            m Asian-American              m Caucasian       m Latino               

m Native American             m Other                 m Unknown

Formal Education (Highest year of school completed)          m Some high school          m GED  m High school     m Some college                  m College             m Post-graduate                 m Other                 m Unknown

What is your primary Language?          mEnglish              m Spanish            m Signing m French      

m Other                                                                

Do you speak another/secondary Language?    m French              m Signing             m Spanish           

m Other                                

Referred by   m Flier                   m Friend               m Internet             m Local newspaper           m Local radio      

m National media               m NCASAA           m Other                 m Unknown          m Volunteer referral agency

Do you drive?       m Yes          m No

Do you have regular access to a car?    m Yes           m No

Driver’s license number                                                                                   Car insurance company______________________

[Date Checked                              Have Coverage?   m Yes m No] - This will be completed by CASA staff

Please list Skills and Interests                                                                                                                                     _______________                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    ____________________________________                                                                        ______________________________________________________                                                                                                                        ______________________________

Please list three references of people (other than relatives) who know you well - preferably people for whom you have worked in either a paid or volunteer capacity:

Name___________________________________________ Phone Number ____________________________________

     Address________________________________________________________________________________________ 

Name___________________________________________ Phone Number ____________________________________

     Address________________________________________________________________________________________

Name___________________________________________ Phone Number ____________________________________

     Address________________________________________________________________________________________

Do you consent to a routine check of your criminal records? m Yes    m No

Can you think of any reason why a judge might be reluctant for you to serve as a CASA Volunteer?

 _______________________________________________________________________________________________________________

CASA of Menominee County reserves the right to make any checks deemed appropriate as to the suitability of anyone responsible for this confidential work.  All information obtained will be held in the strictest confidence.

                                                                                                   Date                                                 

            (Applicants Signature)