CASA of Cecil County · Cecil County Mentors Application

Personal Information

First Name

*

Middle Name

*

Last Name

*

AKA

Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

County

*

Gender

*

Male

Female

Other/Decline

Hispanic?

*

Hispanic

Non-Hispanic

Race

*

Primary Language

*

Birthdate

*

(mm/dd/yyyy)

Home Email

*

Verify Email

*

Work Email

*

Verify Email

*

Best Email

*

Home Phone

*

Cell Phone

*

Work Phone

*

Best Phone

*

Marital Status

Education

Please let us know the type of degree (High School, Associates, Bachelors, etc.) and Major.

Spouse/Partner Contact Info

Spouse/Partner First Name

*

Emergency Contact First Name

*

Emergency Contact Last Name

*

Spouse/Partner Middle Name

*

Spouse/Partner Last Name

*

Spouse/Partner Phone

*

Spouse/Partner Company Name

*

Spouse/Partner Position/Title

*

Emergency Contact Info

Same as Partner/Spouse

Emergency Contact Phone

*

Emergency Contact Phone 2

*

Emergency Contact Relationship

*

Experience

Child Protective Agencies

*

Yes

No

Child Protective Agencies Explanation

If you checked "Child Protective Agencies", please explain.

Foster Care

*

Yes

No

Foster Care Explanation

If you checked "Foster Care", please explain.

Juvenile Court

*

Yes

No

Juvenile Court Explanation

If you checked "Juvenile Court", please explain.

Other Child Service Agencies

*

Yes

No

Other Child Service Agencies Explanation

If you checked "Other Child Service Agencies", please explain.

Child Abuse or Neglect

*

Yes

No

Child Abuse/Neglect Explanation

If you checked "Child Abuse/Neglect", please explain.

Domestic Violence

*

Yes

No

Domestic Violence Explanation

If you checked "Domestic Violence", please explain.

Mental Illness/Mental Health Treatment

*

Yes

No

Mental Illness/Mental Health Treatment Explanation

If you checked "Mental Illness/Mental Health Treatment", please explain.

How did you hear about our program?

*

Volunteer Experience

# of Organizations

How many Organizations have you volunteered with?

Organization Name (1)

Supervisor First Name (1)

Supervisor Last Name (1)

From Date (1)

(mm/dd/yyyy)

To Date (1)

(mm/dd/yyyy)

Responsibilities (1)

Reason for Leaving (1)

Organization Name (2)

Supervisor First Name (2)

Supervisor Last Name (2)

From Date (2)

(mm/dd/yyyy)

To Date (2)

(mm/dd/yyyy)

Responsibilities (2)

Reason for Leaving (2)

More than 2 Organizations?

That's awesome! We'll get the additional organization info from you in your interview.

Employment

How would you like to enter employment history?

*

Type it in

Upload a resume

Organization/Employer (Most Recent)

*

Supervisor's Name (Most Recent)

*

First Name

Last Name

Supervisor's Email (Most Recent)

Verify Email

Organization/Employer Address (Most Recent)

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Organization/Employer (2)

*

Supervisor's Name (2)

*

First Name

Last Name

Supervisor's Email (2)

Verify Email

Organization/Employer Address (2)

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Resume Upload

Please upload your resume.

Vehicle Information

Do you have access to a vehicle?

*

Yes

No

Do you have a driver's license?

*

Yes

No

Driver's License Number

*

Driver's License State

*

Driver's License Expiration Date

*

(mm/dd/yyyy)

Auto Insurance Expiration Date

*

(mm/dd/yyyy)

Auto Insurance Company Name

*

Background Information

To become a Cecil County Mentor all applicants must pass a background check. The paperwork regarding the background check will be provided during your interview.

Do you have a police record?

*

Yes

No

Police Record Explanation

*

Has there ever been an allegation of child abuse and/or neglect made against you?

*

Yes

No

Allegation Explanation:

*

Personal References

Reference 1 Name

*

First Name

Last Name

Reference 1 Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Reference 1 Phone

*

Reference 1 Email

*

Verify Email

*

Reference 1 Relationship

*

Reference 2 Name

*

First Name

Last Name

Reference 2 Address

*

Address Line 1

Address Line 2

City

State/Province

ZIP/Postal Code

Country

Reference 2 Phone

*

Reference 2 Email

*

Verify Email

*

Reference 2 Relationship

*

Release

By submitting this application, I hereby affrim that all fo the answers provided on my volunteer application are true. I hereby authorize the Cecil County Mentors Program to investigate my background to determine my fitness as a potential volunteer.

I understand that the information requested in this application will be used only for the purpose fo determining suitability as a Cecil County Mentor volunteer. Further, I understand that after the successful completion of my training, I will be expected to serve a minimum of one year in the Mentors program. If unforeseen circumstances prevent me from fulfilling this obligation, I will submit my written resignation to the prgoram director with as much advance notice as possible. 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 Mentor. I will discuss these matters with only those whose person directly involded in the case or who will be consulted for their professional knowledge and expertise.