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CASA of Marion
County, Inc.
Office Phone: 503.378.6327
x297
FAX:
503.378.3700
Pam Sornson, Executive Director
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CASA STAFF APPLICATION
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Name
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Address
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City
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State
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Zip
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Phone
Numbers
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(Home)
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(Work or cel)
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(Email Address)
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Are you employed?
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Yes No If yes, Full-time Part-time
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May you be called at work?
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Yes
No
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Please attach a resume that includes the name, location,
contact name and number, and duties at your place(s) of employment for the
past five (5) years.
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Social Security Number
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Driver’s License No.
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State
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Race
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Date of Birth
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Marital Status
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Do you have children?
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Yes
No
If yes, what are their ages?
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In case of emergency,
please call:
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Phone
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Relationship
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Education
(circle highest completed)
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High School:
9 10
11 12
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College:
1 2
3 4
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Graduate:
1 2
3 4
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Major(s)
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Degree(s)
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Do you speak a foreign language?
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Yes
No
If yes, which language(s)?
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Do you drive?
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Yes
No
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Do you have regular access to a car?
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Yes
No
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List current and previous community activities/volunteer work:
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The nature of your work as a staff member necessitates some
flexibility of working hours on occasion.
Please describe any concerns you may have about this:
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Have you had any personal experience(s) involving:
DHS
Child Welfare System Court System
Welfare System
Foster Care
Citizen Review Board (CRB) Other agencies offering services to
children,
adolescents, teens
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Explain:
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We will run a criminal background check on you as a
condition of employment. Is there anything in your background that might raise
concerns about your employment with CASA?
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Have you ever
been convicted of a crime other than a traffic violation?
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Yes
No
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Charge(s)?
Conviction
Date(s)?
Location?
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If deemed necessary, you will be required to complete 35-40
hours of training; and a minimum of 12 hours per year of in-service training
– are you able to commit to these requirements?
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Yes
No
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Please answer the
following questions on a separate piece of paper.
- What background do you
have that would be helpful in working with volunteers?
- How did
you learn of the CASA program? What
interests you about working for CASA?
- Describe your
leadership style.
- Describe
a situation where you have had to work as part of a team to achieve a
result. What was your role in this?
Reasons for Rejecting an Application Please be advised: MC CASA reserves the
right to refuse entry to the program to anyone.
Reasons for
rejecting of an application to become a volunteer or staff member for CASA of
Marion County, Inc. may include, but are not limited to:
- the application is incomplete, inaccurate, or
otherwise unsatisfactory;
- the applicant failed
to sign a release of information for appropriate law enforcement and
reference checks;
- references are not returned or are
unsatisfactory;
- criminal records
and/or DHS check is unsatisfactory;
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the
applicant has abuse/neglect allegations, is currently involved or potentially
involved with the Department of Human Services (DHS), has pending litigation as
a victim or survivor of abuse, is currently in treatment for substance abuse,
has physically, sexually or emotionally abused or exploited a child, or related
acts that would pose a risk to children or the CASA program’s credibility,
holds values in conflict with CASA of Marion County, Inc.'s core values, or is
otherwise deemed unsuitable;
- the applicant has
falsified or misrepresented written or other information;
- the applicant has been
sanctioned or faces disciplinary action by a professional licensing or other
governing body;
- existence of a
conflict of interest which cannot be resolved;
- in the estimation of
CASA staff, it becomes apparent through the training process that the
applicant will be incapable of fulfilling the role of a staff member for CASA of Marion County, Inc.;
- failure to complete
required pre-service training; or
- any other
reason which exists that gives CASA of Marion County, Inc. cause for
concern regarding the applicant's ability to perform the tasks associated
with being a staff person.
I, hereby affirm that all of the answers
provided on my employment application are true. I authorize CASA of Marion
County, Inc. and any law enforcement agency or service they utilize to
investigate my background to determine my fitness as a potential employee.
I
understand that the information requested in this application will be used only
for the purpose of determining my suitability as a Marion County CASA employee.
I am aware of the sensitive and confidential nature of the official
documents, reports and other material I will examine in my capacity as a CASA
employee. I will discuss these matters
only with those persons directly involved in the case or who will be consulted
for their professional knowledge and expertise.
I
also understand that if for any reason it becomes apparent that my activities
are contrary to the policies, goals and/or philosophy of the CASA program and
their desire to provide quality services to abused and neglected children, my
services as a CASA employee will be terminated.
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Name
(please print)
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Signature
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Date
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References
Please
list four (4) people on page 4 of this application who would be able to provide
a knowledgeable reference for you. Do
not list relatives. Please include
at least one person who knows you in a professional capacity such as education,
employer, pastor or community service personnel.
1.
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Name
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Address
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Relationship
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2.
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Name
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Address
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3.
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Name
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Address
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4.
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Name
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Address
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Relationship
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Sunday, September 05, 2010
