Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

I understand that if I am selected to move forward, I will need to pass a thorough background check in accordance with National CASA/GAL standards before being accepted to the board of directors and every four years thereafter, to include: • reference checks from 3 unrelated contacts • criminal records check from the court jurisdiction in which I currently reside and work • state criminal records check • national criminal records check • national sex offender registry check • child protective services check • social security number check or the equivalent that allows for additional names, aliases and/or addresses to be obtained for further checks

Yes

No