1901 Ave. I 141 E. Nopal Hondo, TX Uvalde, TX Phone: Phone: Fax: Fax:

BLUEBONNET CHILDRENS ADVOCACY CENTER TRI-COUNTY CASA APPLICATION FOR EMPLOYMENT 1901 Ave. I Hondo, TX 78861 Phone: 830-426-8848 Fax: 830-426-8883 14...
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BLUEBONNET CHILDRENS ADVOCACY CENTER TRI-COUNTY CASA APPLICATION FOR EMPLOYMENT

1901 Ave. I Hondo, TX 78861 Phone: 830-426-8848 Fax: 830-426-8883

141 E. Nopal Uvalde, TX 78801 Phone: 830-278-7733 Fax: 830-278-7799

GENERAL INFORMATION Name: _________________________________________ Social Security Number: _____________________

Date: ______________

Date of Birth: __________________

Address: _________________________ City _____________ State_______ Zip________ Home Phone: _______________________ Business Phone: _________________________ Fax: ________________________ In case of emergency call:

E-mail Address: ____________________________

_______________________Phone: ____________________

Marital Status: __________ Name of spouse: _____________________________________ Spouse Employer: ________________________________ Bus. Phone: ________________ Children’s Names: ___________________________________________ Age: ________ ___________________________________________ Age: ________ ___________________________________________ Age: ________ Educational: □ High School Diploma ▪ School Name _______________________ □ G.E.D.

□ College Degree ▪ Degree _______________ College Name_______________________

EMPLOYMENT HISTORY

Starting with present or most recent employer, please list your employment history for the last five years. Include self-employment and summer and part time jobs. If more space is required, please continue on a separate sheet. 1. Employer Name: _______________________________________________________ Employer address: ________________________________________________________ Phone Number: _________________ How Long? ___________ Part or Full time: _________________ In what capacity: _________________________ 2. Employer Name: ______________________________________________________ Employer address: ________________________________________________________ Phone Number: _________________ How Long? ___________ Part or Full time: _________________ In what capacity: _________________________ 3. Employer Name: ______________________________________________________ Employer address: ________________________________________________________ Phone Number: _________________ How Long? ___________ Part or Full time: _________________ In what capacity: _________________________ If additional listings are appropriate please list on a separate page and attach to application. VOLUNTEER INFORMATION Volunteer experiences:

Current

1.

______________________________________________________________ ( )

2.

______________________________________________________________ ( )

3.

______________________________________________________________ ( )

4.

______________________________________________________________ ( )

If married, how does your spouse feel about your working for the Bluebonnet Children’s Center/Tri County CASA? ________________________________________________________________________ 2

Hobbies or other non-work interests: ______________________________________________________________________________ ______________________________________________________________________________ What do you feel are the strengths and weakness that you will bring to this program? (i.e. background in counseling, legal, bilingual, etc.; hindrances such as health, family obligations, limitations on hours available). 1.

____________________________________________________________________

2.

____________________________________________________________________

3.

____________________________________________________________________

List any secondary language(s); including signing, you may speak: _______________________________________________________________________ Have you had a personal experience involving the following? Child Protective Services___________________________________________ Probation (Adult)__________________________________________________ Domestic Violence________________________________________________ Drug or Alcohol Issues_______________________________________________ BACKGROUND INFORMATION Due to the nature of the Bluebonnet Children’s Advocacy Center / Tri County CASA volunteer’s responsibilities and contacts, a background check of applicants will be conducted by various law enforcement agencies. √ A criminal background check will be conducted through Choice Point/Volunteer Select Plus and Texas Department of Public Safety to include a local, state and national check. √ Your information will also be processed with the Texas Department of Family and Protective Services to check for any history with Child Protective Services/ Child Abuse Registry. √ Your information will also be processed through the National Sex Offender Registry. Bluebonnet Children’s Advocacy Center does not accept applicants if they or an immediate family member have been convicted of, or have charges pending for, a felony or misdemeanor involving a sex offense, child abuse or neglect, or related acts that would pose risks to children or to the CASA program’s credibility. 3

Have you ever been convicted of, charged with, or arrested for any felony of any type or misdemeanor classified as an offense against a person or family, public indecency, or a violation of the Texas Controlled Substances Act? ___ Yes ___ No If yes, please explain ______________________________________________ Are you under current indictment or has a district/ county attorney accepted an official complaint for any of the above listed offenses? ___ Yes ___ No If yes, please explain ______________________________________________ Have you ever been accused of inappropriate behavior with a child? ___ Yes ___ No If yes, please explain _______________________________________________ REFERENCES Please list 3 personal references. At least one reference must be someone other than a friend or co-worker. For example: minister, rabbi, teacher, employer, therapist, etc. References from relatives cannot be accepted. Name: Mr./Ms./Mrs. ____________________________________________________ Address: _____________________________________ Zip ___________________ Phone: __________________________ Relationship: _______________________ Name: Mr./Ms./Mrs. ____________________________________________________ Address: _____________________________________ Zip ___________________ Phone: __________________________ Relationship: _______________________ Continued from page 5

Name: Mr./Ms./Mrs. ____________________________________________________ Address: _____________________________________ Zip ___________________ Phone: __________________________ Relationship: _______________________ DRIVER’S LICENSE INFORMATION All volunteers must have a valid driver’s license on file with the Executive office.

APPLICANT BACKGROUND CHECK ACKNOWLEDGEMENT FORM

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Because of the confidential nature of serving children who have been abused, neglected or abandoned, as a matter of routine, the Bluebonnet Children’s Center requires that each prospective board applicant give permission and provide information necessary for the background check to be performed. In order to comply with this requirement, you will be required to sign an authorization for criminal background check (local, state, and national), child abuse registry check, and a national sex offender check. I agree that the Bluebonnet Children’s Center may review any information obtained by these background check. I further understand if I do not comply with this procedure and/or the guidelines set forth in the Volunteer Background Check Acknowledgement Form, I will not be able to become a Bluebonnet Children’s Center Board member. I hereby acknowledge that I have been informed that the Bluebonnet Children’s Advocacy Center is contacting the Texas Department of Family and Protective Services to obtain information on Child Protective Services involvement and Choice Point/Volunteer Select Plus to obtain criminal history information. I understand that any information obtained will be used to aid in determining my qualifications for services as a volunteer for the Bluebonnet Children’s Advocacy Center. I understand that the Bluebonnet Children’s Advocacy Center reserves the right to reject any volunteer who has been convicted of, charged with, or arrested for any felony of any type or any misdemeanor classified as an offense against a person or family, public indecency, violation of the Texas Controlled Substances Act, or involving violence of any kind. I understand that qualities of a successful board member include interpersonal skills, compassion, punctuality, and reliability. I further understand that if concerns arise the Bluebonnet Children’s Advocacy Center Program Director reserves the right to reject an applicant at any time. I understand that all information provided to and obtained by the Bluebonnet Children’s Advocacy Center will be held in the strictest of confidence. The Bluebonnet Children’s Advocacy Center may, however, disclose to other agencies and organizations, which utilize volunteers, the fact that I applied for and/or served with the Bluebonnet Children’s Advocacy Center as a board member. Furthermore, all information obtained by the Bluebonnet Children’s Advocacy Center will be deemed to be the sole property of the Agency, and shall not be available to me or anyone outside the Agency. 5

Signature ________________________________________ Date ________________________ Printed Name ____________________________________

Please return this completed application to the Bluebonnet Children’s Advocacy Center at the address on the first page. Allow ten working days for response.

Office Use Only: Received:

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Board Review:

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Board Approved / Rejected: ___/___/___

Signature of Board President:

Date: ___/___/___

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