Fill and Sign the Volunteer Guardian Ad Litem Application Vermont Judiciary Form

VOLUNTEER GUARDIAN AD LITEM APPLICATION Revised July 2015 GAL Program Screening Policies Applicants to the GAL Program must: 1. FILE AN APPLICATION FORM available from: a. GAL Program, Office of the Court Administrator 109 State Street, Montpelier, VT 05609-0701 b. www.vermontjudiciary.org - Favorites/Court Programs/GAL c. or Your local Family Court. 2. CONSENT TO A BACKGROUND CHECK The Vermont GAL Program is required to run a background check on all applicants. To be considered for acceptance to the GAL Program, you must sign a release which permits the GAL Program to secure records checks concerning your background, including criminal records, as authorized by law. The GAL Program has the right to reject any applicant found to have been convicted of, or having 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 the CASA/GAL program’s credibility. 3. INTERVIEW All applicants will be interviewed by GAL Program or local county court staff and referred for initial pre-service training, if appropriate. 4. COMPLETE PRE-SERVICE TRAINING All applicants must have 32 hours of approved pre-service training. Training schedules and locations will be determined by the GAL Program Office. Applicants who complete training to the satisfaction of the GAL Program will be awarded a certificate of training completion and will be accepted to the GAL Program. VOLUNTEER GUARDIAN AD LITEM APPLICATION Revised July 2015 Page 1 The Guardian ad Litem Program must carefully screen all applicants entrusted with determining the best interests of children involved in court proceedings. Please help us by providing complete and accurate information for all questions. Name: ________________________________________________________________________________ __________________ Address: ___________________________________________________________________________ _______ ______________ City/State/Zip: ______________________________________________________________________ _______ _______________ Phone: (Day) ___________________________ (Evening): _____________ ____________ (Cell): _________________________ Email address: ___________________________________________________________________________________________ County in which you wish to be a GAL: _______________________ How long have you been a resident of Vermont? ______ __________ How long at your current address? ___________________ Please list any other cities and states of residence within the past five years: ________________ __________________________ _________________________________________________________________ ______________________________________ If you are or have been known by other name(s), please list: _______________________________________________ ________ We are coll ecting this data for a diversity project. If appropriate, you may check more than one box . Gender: Male Latino/Hispanic: Race: African American Asian Caucasian Native American Female Yes No Unknown Not Known Other______________________ In case of emergency, please contact (name & phone): _________________________________________________ __________ Do you drive? Yes No Do you have regular access to a car? Yes No Education: Please circle highest level completed, or please attach your resume. High School : 9 10 11 12 High School: (Name & City/State): ____________________________________________ Major: ____________________________________ Degree or GED : Yes No College: 1 2 3 4 5 College last attended: (Name & City/State): ____________________________________________ Major(s): _______________________________________ Degree(s): ____________________________________________ Graduate: 1 2 3 4 Graduate School: (Name & City/State): ____________________________________________ Major(s): _______________________________________ Degree(s): ____________________________________________ Please list any languages you speak other than English (including American Sign Language): ____________________________ Other Training: __________________________________________________________________________________________ Employment History : Please complete the employment history section or attach your resume. Are you currently employed? Yes : ( Full-time Part-time Self-employed) No Retired Current Employer: _________________________________________________________________________________________ Current Employer Address: ________________________________________________________________________________ __ Your role or position: _______________________________ Your supervisor’s name: _________________ _________________ Phone: __________________________________________ May we contact you at work? Yes No VOLUNTEER GUARDIAN AD LITEM APPLICATION Revised July 2015 Page 2 Please list any other employers in the past ten years, include the company name, city/state in which the company resides , your position, your supervisor’s name (use additional sheet(s) if necessary): ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ Please list any experience working with children: _____________________________________________________________ _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ Please list ALL current and previous volunteer work (include name of agency/program and contact person): ____________ ___ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ Are you willing to commit to at least to two years of service as a Guardian ad Litem? Yes No How did you hear about the Guardian ad Litem Program? (You may check more than one) Newspaper: _____________ ___________________ __ Radio T.V. Friend GAL Court Staff Other: _____ _________________________________ _ Have you heard a VPR ad for the GAL Program? Yes No Do you, or any family members, have ANY personal experience involving the following services or agencies? (Check all that apply) Department for Children & Families (DCF) Vermont Court System Foster Care GAL/CASA References: Please list three people who will provide a knowledgeable reference for your potential work as a Guardian ad Litem and include at least one person who knows you in a work or professional capacity. Do NOT list relatives. Name Type of Reference Phone Number Complete Mailing Address _______________________________ _______________ _______________ __________________________________ __________________________________ _______________________________ _______________ _______________ __________________________________ __________________________________ _______________________________ _______________ _______________ __________________________________ _________________________________ Please write a brief statement about why you have chosen to volunteer for the Guardian ad Litem Program at this particular time in your life. Use additional sheet(s), if necessary. ___________________________________________________________________________________ ______________________ ___________________________________________________________________________________________________ ______ ___________________________________________________________________________________________________ ______ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ VOLUNTEER GUARDIAN AD LITEM APPLICATION Revised July 2015 Page 3 Have you been charged with or convicted of any crime? Yes No If yes, please explain: Use additional sheet(s), if necessary. ________________________________________________________________________________________________________ _________________________________________________________________ _______________________________________ ________________________________________________________________________________________________________ I hereby agree to do the following: 1. Apprise the Guardian ad Litem Program (if accepted to the Guardian ad Litem Program) if I am arrested, charged with, or convicted of any crime while my application is pending or during the tenure of my service in the Guardian ad Litem Program. 2. Abide by all Judiciary and Guardian ad Litem Program Policies an d Procedures. 3. Affirm the information provided in this application is accurate and true. I understand any misrepresentation is grounds for dismissal from the Vermont Guardian ad Litem Program. 4. Authorize the Office of the Court Clerk and/or the Coordinator of the Vermont Guardian ad Litem Program to investigate my background and check my character references. I willingly consent to this release of information as part of my application to become a Guardian ad Litem, and authorize all relevant agencies and individuals to release any information requested by the Office of the Court Clerk or Guardian ad Litem Program. I understand that requests for information may be submitted to past and present employers, law enforcement agencies, criminal and civil courts, social service agencies, and any other individuals or organizations with which I have had contact in the past. I understand that this information will not be disclosed to any third party, and will remain confidential. I understand a photocopy of this release shall be deemed the same as the original. Sig ned: _______________________________________________ Date: __________________________________ ________ Print Name: ____________________________________________ Please sign and mail to: Vermont Guardian ad Litem Program Office of the Court Administrator 109 State Street Montpelier, VT 05609-0701 Phone: 800-622-6359 Email: jud-vermontgal@vermont.gov website: www.vermontjudiciary.org Thank you for your application. VOLUNTEER GUARDIAN AD LITEM APPLICATION Revised July 2015 Page 1