Complete this on-line application or printable copy to mail or fax to the address below. Thank you for your interest and support.
Date of Birth: month January February March April May June July August September October November December day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 year
Address:
City: State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Permanent Address (check here if the same as above):
Phone: (numbers only, ie: 7158364357) day evening
Social Security #
Driver's License: State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY #
List any other names you have had:
List all counties and state in which you have lived in as an adult:
Which volunteer opportunities are you interested in (check all that apply)? Crisis Line Advocate Outreach Program development other Specify any other volunteer interests with CASA:
By submitting the above information, you assert that the information is true to the best of your knowledge and hereby give the Family Support Center permission to conduct criminal record and driver's license checks as required for their program.
University of Wisconsin - Eau Claire 55 Brewer Hall Eau Claire, WI 54702-4004
(715) 836-HELP e-mail CASA
