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Citizens Against Spouse Abuse Volunteer Application

Due to the sensitive nature of our mission, CASA requires all volunteers to register through the Missouri Department of Health and Senior Services Family Care Safety Registry.

Volunteers may opt out of this registration, but they will not be allowed to volunteer within the shelter. They may still volunteer outside of the shelter (collecting donations, helping at fundraisers, etc.).

By entering the information and signing this application, you agree to allow CASA to enter your information on the above-mentioned website to register you or verify your existing registry in the Family Care Safety Registry:

Agreement of Application

I agree the information in this application is to the best of my knowledge. If CASA discovers anything is untrue, my volunteer hours may be terminated immediately and may not be validated. It is at the discretion of the Volunteer Coordinator and Executive Director, depending on the circumstances.

Printed Name *

Date *

Please fill out the Family Registry form. Save it with your changes, information and signature in it and upload the file here. *

Staff Signature *

Date *

Domestic Violence Quiz

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Please write T or F on the space provided next to each statement.

Please write T or F on the space provided next to each statement. *

T or F
1. Domestic violence is not a problem in your community.
2. Couples counseling is recommended by The Hotline for abusive relationships.
3. Sometimes the victim provokes their partner into abusing them.
4. Yelling, putting down or belittling someone isn’t ever considered abuse.
5. On average, more than 3 women are murdered by their partners every day.
6. If the abuse was getting too bad, the victim would just leave.
7. The most dangerous time for a victim is often when their partner first lashes out.
8. Everyone deserves respect in a relationship.
9. If children aren’t being abused and don’t witness the abuse, they aren’t affected.
10. Domestic violence imposes a significant financial cost on society.

Confidentiality Agreement

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As a visitor, agency representative, vendor, volunteer, staff member, or participant in CASA’s services and by the signing of this agreement, I agree to abide by the confidentiality terms established in the Missouri Revised Statues (MoRS 455.220) in order to ensure the safety of program participates, volunteers, and staff. “To qualify for funds allocated and distributed pursuant to section 455.215 a shelter shall meet all of the following requirements. 455.220.1.5 require persons employed by or volunteering services to the shelter to maintain the confidentiality of any information that would identify individuals served by the shelter and any information or records that are directly related to the advocacy services provided to such individuals. 455.220.2 Any persons employed by or volunteering services to a shelter for victims of domestic violence shall be incompetent to testify concerning any confidential information described in subdivision (5) of subsection 1 of this section, unless the confidentiality requirement is waived in writing by the individual served by the shelter.” As a visitor or employed contractor, I agree to share no information regarding CASA’s facility location nor identifying information about any participants whom I visit or observe while visiting CASA’s program. The only exception ask, if a CASA participants is also a client of mine, then only that information necessary for successful service by my organization will be shared within my organization on a need-to-know basis. No exceptions to this agreement shall be made regarding the confidentially of persons whom I observe to be a part of CASA’s program and who are NOT my clients. This confidentiality of shelter location, personal identifiers and records of shelter services shall include physical descriptions of individuals, family members, vehicles and recognizable circumstances. I understand that this agreement applies to all forms of verbal, written and electronic communication. I understand that wireless instruments such as wireless or cellular phones, and personal data instruments, are NOT a secure form of communication, and the above types of information are not to be discussed while using wireless instruments, even with the written permission of the participant. In addition to personal communication of this information, I have been informed that, unless I am the designated custodian of records for CASA, I may not testify in court regarding the above information unless assigned to do so by the Executive Director or President of the Board of Directors of CASA. I agree to operate by the above confidentiality principles both during services as a representative to CASA as well as after I leave the relationship of CASA visitor, vendor, or volunteer. To protect the privacy and confidentiality of CASA’s facility and its participants, no video chatting, video recording, or mentioning of other client names while speaking on the phone to friends, family or acquaintances is permitted. These offenses will result in your termination from shelter. *

Printed Name *

Date *

Reason for Visit *

Organization or Business *

Staff Signature *

Staff Printed Name *

Date *

Understanding and Mitigating the Risks

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WARNING

Understanding and Mitigating the Risks of Experiencing Triggers and Re-traumatization

Please check the box at the end to indicate that you have read this information.

As you prepare to start your volunteer work at CASA, it is important to be aware of potential triggers and re-traumatization that you may encounter while working within this environment.

While working within our shelter, you may encounter situations, conversations, or behaviors that are emotionally distressing or triggering. This environment involves intense and heavy emotional experiences, stories of abuse, and traumatized persons.

So, if you have personal experiences with trauma, especially related to domestic or sexual violence, please be aware that certain interactions might bring up past memories and feelings. It is crucial that you monitor your own emotional well-being and seek support if needed.

Re-traumatization can of this information to indicate you have read these warnings.manifest differently in each person, but here are some general warning signs that you should be cautious of:

1. Physical Symptoms

1. Feeling anxious or tense

2. Trouble sleeping

3. Changes in appetite or weight

4. Fatigue

5. Strong reactions to triggers

2. Emotional Symptoms

1. Intense feelings of guilt, anger, anxiety, horror, sadness, shame, or despair

2. Negative thoughts about oneself or the world

3. Difficulty feeling positive emotions

3. Behavioral Symptoms

1. Social withdrawal

2. Isolation

3. Avoidance of people, places or situations

4. Increased substance use

4. Other warning signs include:

1. Flashbacks

2. Panic attacks

3. Dissociation

4. Self-Neglect

5. Self-Harm

6. Depression

7. Fear of Reoccurrence

Additionally, here are some tips to manage triggers and prevent re-traumatization:

1. Self-Care: Engage in activities that help you relax and decompress after you volunteer.

2. Boundaries: Establish and maintain healthy boundaries with both residents and staff. Let us know what your limits are.

3. Breaks: It is okay to step away and regain your composure and realign yourself. Take breaks when you need them.

4. Support Systems: CASA offers a variety of support through our program that you can take advantage of. However, you should also try to have support systems outside of our shelter such as family, friends, or anyone you trust that you can confidently confide in.

5. Self-Awareness: No one knows you better than YOU. If you notice something is not quite right after checking in with yourself, you are probably not imagining it.

Resources:

National Sexual Assault Hotline (RAINN): 1-800-656-HOPE (4673)
National Domestic Violence Hotline: 1-800-799-SAFE
Suicide Hotline: 1-800-SUICIDE (784-2433)
Gay and Lesbian National Hotline: 1-888-843-4564

Assumption of Risk and Release Form

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THIS IS A RELEASE OF LEGAL RIGHTS – READ AND UNDERSTAND BEFORE SIGNING

Name *

Date of Birth *

Activity *

I hereby agree as follows:

1. Risks of activity. I understand that participation in this Citizens Against Spouse Abuse (hereafter, “CASA”) activity involves risks. These risks include but are not limited to physical/bodily harm and death. I acknowledge and accept all known or unknown risks.

2. Nature of activity.

A. I understand that CASA is not responsible for matters that are beyond its control.

B. I understand that I am participating voluntarily and that CASA is not responsible for any injury or loss I may suffer.

C. I hereby release CASA from any injury, loss, damage, accident, delay or expense arising out of my participation in this activity.

3. Health and Safety.

A. I have consulted with a medical doctor with regard to my personal medical needs. There are no health-related reasons or problems which preclude or restrict my participation in this activity.

B. I have arranged, through insurance or otherwise, to meet any and all needs for payment of medical costs during or otherwise related to my participation in the activity. I recognize that CASA is not obligated to attend to any of my medical or medication needs and I assume all risk and responsibility therefore. If I require medical treatment or hospital care during or related to the activity, CASA is not responsible for the cost or quality of such treatment or care.

C. CASA may, but is not obligated to, take any actions it considers to be warranted under the circumstances regarding my health and safety. I agree to pay all expenses relating thereto and release CASA from any liability for any action or inaction.

4. Standards of Conduct.

A. I will comply with CASA’s rules, policies, standards and instructions. I waive and release all claims against CASA related to my failure to comply with such rules, policies, standards and instructions.

B. I agree that CASA has the right to enforce the standards of conduct described above in its sole judgment, and that it will impose sanctions, including expulsion from the activity, for violating these standards or for any behavior detrimental to or incompatible with the interest, harmony, and welfare of CASA, the activity, or other participants.

5. Activity Changes. CASA has the right to make cancellations, substitutions or changes in case of emergency or changed conditions or in the interest of CASA. If I leave or am expelled from the activity for any reason, there will be no reimbursement of costs incurred. I accept all responsibility for loss or additional expenses due to delays, sickness, weather, strikes, or other unforeseen causes.

6. Assumption of Risk and Release of Claims. Knowing the risks described above, and in consideration of being permitted to participate in the activity, I agree, on behalf of my family, heirs, and personal representative(s), to assume all the risks and responsibilities surrounding my participation in the activity. To the maximum extent permitted by law, I release and indemnify CASA, its officers, trustees, employees and agents, from and against any present or future claim, loss or liability for injury to person or property which I may suffer, or for which I may be liable to any other person, during my participation in the activity, including periods in transit to or from any state or location where the activity is being conducted.

I have carefully read this Assumption of Risk and Release Form before signing it. No representations, statements, or inducements, oral or written, apart from the foregoing written statement, have been made. This agreement shall be governed by the laws of the State of Missouri.

Date *

Printed Name of Parent or Legal Guardian (if volunteer is a minor): *

Signature of Parent or Legal Guardian (if volunteer is a minor): *

Date *

Please provide emergency contact information: *

Name Phone Number Relationship
1
2

Content/Photo Release

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Printed Name *

Date *

Signature *