Application Part One

Date:

First Name:

Last Name:

Middle Name:

Maiden Name:

Social Security #:

Gender:

Present Address:

Permanent Address:

Cell Phone:

E-Mail Address:

Date of Birth: (Required for background check)

Driver’s License/ID #:

County:

State:

Marital Status:

Place of Birth:

County:

State:

Name and Complete Address of Parents or Nearest Relative to be called in Case of Emergency:

Citizenship Status:

Current Visa Status:

How did you hear about Casa de Esperanza?

Date you can begin the internship:

Are you currently employed?

YES NO

If yes, may we contact employer?

YES NO

Can you, at the time of employment, submit verification of your legal right to work in the United States?

YES NO

EDUCATION RECORD: To work with Casa de Esperanza, you must have at least a high school diploma or GED in order to meet minimum licensing standards in Texas. Please obtain one of the following, which is to be from the highest education level you’ve achieved.

A photocopy of your High School Diploma
An official copy of your High School Transcript
A copy of your GED Certificate
An official copy of your College/University Transcript
A photocopy of your College/University Diploma

IMPORTANT NOTE: If you need to request your transcript or diploma, please complete and return part one of the application first.You can send us your education record later once you have obtained it.

A. High School and Undergraduate:

Institution	Degree	City	State	From	To	Major Areas

Special Endorsements/certificates/licensures:

B. Graduate Education:

Institution	Degree	City	State	From	To	Major Areas

C. Foreign Language Speaking Ability:

Employment History — list most recent first

Company Name:

Supervisor:

Last Position:

Responsibilities:

Telephone No:

Address-1:

Address-2:

City:

State:

Zip:

Started Date:

End Date:

Reason for Leaving:

1. Have you ever been licensed as a foster parent?

YES NO

If yes, please list the agency or agencies that licensed you.

2. Has an immediate relative of yours worked for the Texas Department of Family and Protective Services (TDFPS) in the previous four years?

YES NO

If Yes, please list relative’s full name and department in which they were employed:

MILITARY RECORD

Type of Discharge:

Service #:

Branch of Service:

Started Date:

End Date:

Highest Rank Held :

VOLUNTEER PROGRAMS:
List any programs/volunteer projects you have participated in

Organization	Start	End	Your Role

REFERENCES:
list 3 individuals [not related to you] who are familiar with your work-related or academic skills. List two individuals who know you well and can provide a character reference. List two family members who can be contacted as a reference.

Ref. Type	Relationship or Name of company	E-mail Address	Telephone No.	Years Acquainted

Statement of Liability Release and Waiver of Inspection

I, authorize the people named as references above on this application to give Casa de Esperanza, any information (including opinions) that they may hold regarding my character or fitness for work with children. In consideration of the receipt and evaluation of my application by Casa de Esperanza, I hereby release Casa de Esperanza, any individual, organization, charity, employer, reference, or any other person or organization, including record custodians, both collectively and individually, from all liability for damages of whatever kind or nature which may at any time result to me, my heirs, or family, on account of compliance or any attempts to comply with this authorization. I waive any right that I may have to inspect any information provided about me by any person or organization identified by me in this application.

I further state that I have carefully read the foregoing release and know the contents thereof and I sign this release as my own free act. This is a legally binding agreement which I have read and understand.

Applicant's Signature:

Date:

Print Name:

Self Reference Questions

Please type a self-reference that address the following areas:

Describe your personality. Include outstanding characteristics which make an impression on others.
Why are you interested in working at Casa de Esperanza?
Describe your work style.
Describe your ability to work, live, and interact with diverse populations.
How do you deal with conflict? Give an example.
Are there any other comments you wish to make?

Upload Document: * doc and pdf files only

CRIMINAL HISTORY:

Review the following statements. Check the answer that appropriately describes your situation. Initial each statement, then sign and date at the bottom.

Initial below

1. Have you ever been arrested at any time during your life?

YES NO

2. Have you ever been arrested without a conviction?

YES NO

3. Have you ever been charged with a pre-trial diversion?

YES NO

4. Have you ever received deferred adjudication?

YES NO

5. Have you ever been convicted of a misdemeanor?

YES NO

6. Have you ever been convicted of a felony?

YES NO

7. Have you ever been on probation during any time of your life?

YES NO

If you responded ‘Yes’ to any of the above, please describe the circumstances and situation. Include the type of offense, felony and/or misdemeanor charges, probation terms, convictions and/or pending criminal charges in the following spaces. Also include the county, State, date and case disposition.

Please Note:
According to State Licensing Regulations, all new employees must submit to and pass, an initial drug screening before they begin employment or service with the agency. The drug test will typically be conducted here, on sight, before you are allowed to have any access to the children in care. Random drug screenings will continue throughout employment or volunteer service with the agency.

Certification, Release and Authorization Form

CERTIFICATION
I certify that all statements made by me, including in my application, questionnaire and interview are true, complete and correct to the best of my knowledge and belief, are made in good faith, and that I have withheld nothing that would, if disclosed, affect this application unfavorably.

AUTHORIZATION FOR RELEASE OF INFORMATION
I hereby give Casa de Esperanza de los Ninos, Inc. permission to contact my present employer(s), associates, educational institutions, law enforcement agencies, and other individuals and agencies deemed necessary in determining my eligibility for becoming a foster parent and/or volunteer with the agency.

CRIMINAL BACKGROUND HISTORY SCREENING: CONSENT FOR CRIMINAL BACKGROUND HISTORY CHECK AUTHORIZATION/WAIVER/INDEMNITY
I hereby give my permission in exchange for good and valuable consideration for Casa de Esperanza de los Ninos, Inc. to obtain information relating to my criminal history record through DFPS and other criminal record agencies. The criminal history record, as received from the reporting agencies, may include arrest and conviction data as well as plea bargains and deferred adjudication. I understand that this information will be used, in part, to determine my eligibility for an employment/volunteer position with this organization. I also understand that as long as I remain an employee or volunteer here, the criminal history records check may be repeated at any time. I understand that I will have an opportunity to review the criminal history and a procedure is available for clarification, if I dispute the record as received.

I, the undersigned, do, for myself, my heirs, executors and administrators, hereby remise, release and forever discharge and agree to indemnify and defend Casa de Esperanza and each of their officers, directors, employees, and agents harmless from and against any and all causes of actions, suits, liabilities, costs, debts and sums of money, claims and demands whatsoever, and any and all related attorney’s fees, court costs, and other expenses resulting from the investigation of my background in connection with my application to become a volunteer/staff member.

GENERAL RELEASE OF LIABILITY
On behalf of myself and my heirs, executors and administrators, I hereby release, discharge, and forever hold harmless Casa de Esperanza, the Center and each of their agents, employees, representatives, and directors, from all liability, costs or damages resulting from the investigation of my background in connection with my application to become a volunteer. I agree not to sue Casa de Esperanza, or any of their agents, employees, representatives, or directors, for any claim or cause of action related to or based upon this investigation. If accepted as a volunteer, I hereby agree to abide by all rules and policies of Casa de Esperanza, as explained in the Staff Training Manual, Personnel Manual or state licensing regulations, including any amendments that may be made from time to time. I also agree to notify Casa de Esperanza, immediately in the event that I am indicted for a felony or crime of moral turpitude. I will be advised if a criminal match is reported on my criminal history investigation and Casa de Esperanza has no responsibility to clarify or resolve the matter on my behalf.

My signature indicates that I have read and fully understand the above consent and release.

Applicant’s Signature:

Date:

Applicant’s Printed Name:

Casa de Esperanza Employee Statement

I, the undersigned, state that all of the information given on this application is true and correct to the best of my knowledge.

Signature of Applicant:

Date:

I understand and agree to abide by all the regulations and policies of Casa de Esperanza. For the protection of the children we serve and in respect of their families, a staff member/volunteer is prohibited from seeking or disclosing the contents of any communications, records, and files, except for purposes directly connected with the operation or administration of Casa de Esperanza de los Ninos, Inc. I agree to maintain the confidentiality of all client, volunteer, and donor information.

Signature of Applicant:

Date:

I, the undersigned, state that I have not been arrested for, charged with or convicted of driving a motor vehicle under the influence or drugs or alcohol.

Signature of Applicant:

Date:

According to the Texas Department of Human Resources, Minimum Standards for Child Placing Agencies, persons who have been convicted of certain offenses may not work with children:

I hereby declare that I have NOT been convicted of any felony or misdemeanor classified as an offense against a person or family, or of public indecency, or violation of the Texas Controlled Substance Act.
In addition, I have not been convicted of ANY other felony or misdemeanor. There are no criminal charges pending against me at this time.

Signature of Applicant:

Date:

I understand that a Criminal History Report and Abuse and Neglect Registry check is obtained on all applicants for positions with this agency.

Signature of Applicant:

Date:

I understand that all applicants will have a pre-employment drug and alcohol screen and that as an employee I must abide by all aspects of Casa de Esperanza’s Drug and Alcohol Policy.

Signature of Applicant:

Date:

I, the undersigned, state that I have not been accused of abuse or neglect of a child.

Signature of Applicant:

Date:

***Please be sure you have signed all statements***

	Phone: (713) 529-0639
	Fax: (713) 529-9179
	Email: casa@casahope.org
	P.O. Box 66581 Houston, TX 77266-6581 2911 Corder, Building A Houston, TX 77054