(716) 753-4123 casaofchautauqua@roadrunner.com

Board Profile Form

This form may be downloaded (Microsoft Word or PDF), printed and mailed, or sent to us by email as an attachment. Or fill out the form below, and either print and mail it or submit it online. See also: Board Application Form.

Online Profile Form

Contact Information

Name

Email Address

Mailing Address

Phone Numbers
(h) (w) (c)

Fax

In order to assist the CASA program in determining the extent of representation and diversity on its Board of Directors, please complete the following:

Your Areas of Expertise

Communication/Media
Financial/Investing
Fundraising
Knowledge of CASA
Legal Affairs
Management – General
Marketing
Public Relations
Personnel Relations
Planning
Child Issues
Teaching
Public Safety
Medicine/Psychiatry
Other

Your Community Linkage

Banking
Churches
Corporation/Business
Education
Government/Politics
Health Delivery/Hospital
Law
Media
Mental Health
Medicine/Nursing
Agriculture
Social Services
Unions/Labor
Youth Activities
Other

Demographic Information

Gender

Age

Ethnicity/Race

White
Afro-American
Hispanic/Latino
American Indian
Other

Comments

Please contact our office if no response is received in seven days.