Member Application Form

Legal Last Name:

Legal First Name:

Middle Initial:

County of Residence:

Physical Address (Including Zip Code)

Mailing Address if different than physical address

Email Address

Phone Number

Gender Gender Female Male Other

Race Race Caucasian Asian African-American Native-American Other

Hispanic Hispanic Yes No

Age Age 18-30 31-45 46-64 65+

Family Income: Family Income: Less than $25,000 $25,001 – 40,000 $40,001 – 65,000 Over $65,000

Education: Education: Grade School Associate’s Degree Masters Degree High School Diploma/G. E. D. Technical Degree/Certification Doctoral Degree Some College/Tech Bachelors Degree

Employment: Employment: Employed Retired Unemployed

Employer Name, City, and State

Are you a foster parent? Are you a foster parent? Yes No Former

Are you a Court Appointed Special Advocate (CASA): Are you a Court Appointed Special Advocate (CASA): Yes No Former

Are you, or have you ever been, involved in a child abuse or neglect case as either an alleged perpetrator, witness or victim? Are you, or have you ever been, involved in a child abuse or neglect case as either an alleged perpetrator, witness or victim? Yes No

What are your reasons for wanting to serve as a member?

In submitting this application, I understand that application requirements include interviews, reference and background checks, confidentiality agreements and online/in-person training. I further acknowledge that submitting an application does not ensure acceptance as a SCAC member. In submitting this application, I understand that application requirements include interviews, reference and background checks, confidentiality agreements and online/in-person training. I further acknowledge that submitting an application does not ensure acceptance as a SCAC member. I agree