CASA Tutor Application
Hope College Graves Hall B-40 (616) 395-7944
_____ CASA tutoring is my field placement/community service for: ____________________________________________
Name _____________________________________________ E-mail Address ___________________________________________
Telephone: Cell ________________________________ Home/Local/Other (please specify) ________________________________
Campus/Local Address ________________________________________________________________________________________
Residence Hall/Apt. Off Campus Address
Home/Permanent Address ______________________________________________________________________________________
Please provide the preferred means for us to contact your parents/family with CASA updates:
Name: __________________________________________________ Email: _____________________________________
Mailing address: ______________________________________________________________________________________
Hope ID # ________________________
Student Status: ____First Year ____Sophomore ____ Junior ____Senior ____Other:_______________________
Major __________________________________ Minor ___________________________________
Campus clubs and organizations:_________________________________________________________________________________
Hobbies or Interests: __________________________________________________________________________________________
Please briefly describe any previous work experience with children in educational programs or tutoring (paid or volunteer):
Previous Work Experience:
Dates Company Job Title Type of Work
1. _________________ ______________________________________________________________________________________
2. _________________ ______________________________________________________________________________________
Personal References: (Please provide at least one Hope College reference, if possible):
Are you CPR certified? Yes ____ No _____ Other certifications: _______________________________________
_____ I am interested in a PAID transportation position : _____CASA van driver _____CASA bus rider.
____ I currently have a valid driver’s license that I have held for at least two years.
____ I have a clean driving record.
____ I receive financial aid under the work-study program.
_____ Yes, I speak another language (please list):
_____ Yes, I have been a CASA tutor before. Dates (approximately):
Special requests or comments:
Please indicate the days and times you are available to
_____ Monday/Wednesday 3:35 5:35 pm
_____ Tuesday / Thursday 3:35 5:35 pm
_____ Available for ALL / No preference
_____ Yes, I am willing to tutor a small group
of 2 - 3 students.
Office Use:
I. CASA Tutor Job Description - Volunteer Tutor Applicants Only
CASA tutors are one of the most important elements of the CASA program. By volunteering to work with
underrepresented children, our tutors provide a vital, caring, one-on-one mentoring relationship that encourages
each child’s succeed. Your commitment to the following responsibilities is essential:
1. Attend Tutor Orientation, In-Service Training, and supervision sessions.
2. Tutor two (2) afternoons per week (M/W or T/TR) for two (2) hours each day per semester, unless otherwise noted.
3. Sign in on time and select appropriate work materials in advance.
4. Follow the CASA daily program schedule and use tutoring and enrichment time as instructed by CASA staff.
5. Encourage positive behavior in our children by modeling good listening skills and promoting an atmosphere of safety, mutual
respect, and acceptance.
6. Complete and submit daily reports for tutorial sessions.
7. Remain in the designated CASA rooms for the duration of each day’s program.
8. Notify the CASA office BY NOON if you will be late or unable to work on the day scheduled.
9. Discuss student progress, challenges, and behavioral concerns with the CASA staff.
10. Treat sensitive information from or about your child in a professional manner and follow up with CASA staff.
11. Follow state laws which require reporting of all abuse and/or neglect to the proper CASA authorities.
12. Serve as role models for CASA students by promoting and displaying appropriate behavior and dress. Inappropriate behavior,
including consumption of alcohol, public intoxication, use of illegal substances, abuse of legal substances, profanity, or harassment
will result in immediate termination.
13. Offer only appropriate comments about CASA and about those who provide support (i.e. teachers, counselors, parents, and social
14. Promote the welfare of CASA by referring questions, concerns, or suggestions to the CASA staff.
I have read, understood, and agree to follow the above CASA Tutor Job Description.
Signature________________________________________________________ Date____________________________
II. Background CheckAll Applicants READ CAREFULLY --THIS DOCUMENT CONTAINS A RELEASE (non-certified)
As a prospective employee or volunteer of Children's After-School Achievement (CASA), I understand that it is this agency's policy to
secure conviction criminal history information as part of their pre-employment and volunteer participation screening process using the
information provided below. Further, I understand that my signature on this application grants CASA permission to verify my
academic and behavioral records.
Last First Middle
BIRTHDATE:________________________________ RACE:______________________________________ SEX:_______________
I understand that the above information is required by the central records division of the Michigan State Police, Lansing, Michigan. I
authorize and unqualifiedly grant permission to CASA and its administration to make inquiries and to obtain any records from child
protection agencies, law enforcement and/or judicial authorities to determine whether any record of criminal conviction exists and whether
there are any felony charges pending against me, including the nature of the offenses. I understand that if I work or volunteer for CASA, this
consent form will become part of my personal file and that any misrepresentation, misleading or untruthful statement, or omission is cause
for dismissal should I become a participant in CASA.
I do hereby release CASA, its individual Board members, employees, and/or agents from any and all claims and/or liability whatsoever
for any damages or consequences which may result from the pre-employment investigation and/or physical examination, including the drug
screening test (if applicable), related to my consideration for participation in CASA programs.
Signature__________________________________________________________ Date ____________________________
III. Publicity ReleaseAll Applicants
I give permission for CASA to use my image (photos, digital, video), sound recordings of my voice, and any materials that I submit
during my affiliation with CASA.
Signature________________________________________________________ Date ___________________________
Return to:
263 College Ave., Hope College Graves Hall B-40 PO Box 9000 Holland, MI 49422-
Phone:(616)395-7944 Fax: (616)395- casa@hope.edu www.hope.edu/casa
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