Your Name
*
First Name
Last Name
Your Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Your Phone Number
*
Your Email Address
*
Would you like to be added to our e-mail distribution list?
*
Yes
No
Would you like more information about becoming a CASA volunteer?
*
Yes
No
In what capacity have you known the applicant?
*
How long have you known the applicant?
*
How well do you know the applicant?
*
Very well
Well
Average
Little
How is the relationship between the applicant and his/her children? (if applicable)
*
Good
Average
Mild Conflict
Extreme Conflict
Unsure
Not Applicable
How does the applicant relate to youth in general?
*
Check all that apply
How is the applicants relationship with people in general?
*
Check all that apply
How would you describe the applicant's friendships?
*
Many
Few
None
Unsure
How would you rate the applicant's health?
*
Good
Average
Fair
Poor
Unsure
Check all that describe the applicant:
*
To what extent is the applicant aware of his/her shortcomings?
*
Feels he/she has none
Ignores them
Strives to overcome them
Accepts them
Unsure
Describe the applicant's ability to be flexible:
*
Excellent
Good
Average
Fair
Poor
Unknown
Describe the applicant's ability to assume responsibility:
*
Excellent
Good
Average
Fair
Poor
Unknown
Describe the applicant's temperament:
*
Check all that apply
When the applicant starts projects, how well does he/she finish them?
*
Very well
Well
Average
Fair
Poor
Unknown
Do you consider the applicant emotionally stable?
*
Yes
Usually
No
If you answered no to the question above, please tell us why.
In your opinion, has the applicant ever had a drug or alcohol problem?
*
No
Yes
If you answered yes to the question above, please explain.
How would you rate the applicant's ability to handle confidential information?
*
Excellent
Good
Average
Fair
Poor
Unknown
How would you rate the applicant's ability to be objective and nonjudgmental regarding others' behaviors or lifestyles?
*
Very accepting of others
Somewhat bothered by lifestyles different than own
Intolerant of others who live and act differently
To your knowledge, has the applicant ever had his/her driver's license revoked or suspended?
*
No
Yes
Unsure
To your knowledge, has the applicant ever been accused of, arrested for, or convicted of a crime?
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No
Yes
Unsure
Would you be comfortable having the applicant as an advocate for a member of your family?
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Yes
No
Unsure
Discuss your overall impression of this applicant, addressing any strengths or weaknesses they may have:
*
Would you recommend the applicant for a volunteer advocate role with CASA?
*
Yes
No
By checking this box, you are certifying that everything provided here is true and correct to the best of your knowledge.
*
