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Coming together is a beginning. Keeping together is progress. Working together is success.

CAPTA Panel Application

Thank you for your interest in volunteering to serve on one of Georgia’s CAPTA Panels. CAPTA Panels are charged with examining the state’s child protection system, evaluating the extent to which state and local agencies are discharging their child protection responsibilities, and making recommendations for improvement. Requirements for CAPTA Panel members:

·  Attend and participate in bi-monthly meetings, including an annual all-panel retreat

·  Bring professional expertise and/or personal experience with the child welfare system

·  Maintain objectivity and confidentiality

Please complete and return this application to so that we are able to match your interests and experience to the most appropriate Panel. Please be aware that some Panels have mandated membership requirements that are taken into consideration when assigning new members to a Panel. State and federal law prohibits discrimination based on race, creed, sex, religion, mental or physical disabilities, age or marital status.

All responses will remain confidential.

Name:
Address: / City: / Zip:
Email: / Phone (cell): / Phone (work): / Phone(home):

Current employer and position or responsibilities:

Professional training, degrees, certificates and licenses:

Special skills, interests or relevant experiences:

What strengths do you have that would be beneficial to Georgia’s CAPTA Panels?

How did you become aware of Georgia’s CAPTA Panels?

Why do you want to become a CAPTA Panel member?

Do you have any reservations about serving as a Panel member?

Have you or has anyone in your family been involved with the Social Services or Court systems?
Yes______No______

If yes, please explain.

Have you been convicted of a crime, other than minor traffic violations?
Yes______No______

If yes, please explain.

Additional comments:

I submit the statements on this application are true, complete and correct to the best of my knowledge. I understand that falsification on this application can disqualify me from consideration or result in dismissal from a Panel at a future date.

Signature: / Date:

References

Recommended by CAPTA Panel member:
Provide name and contact information for one additional reference. Please include brief statement describing your relationship.
Name: / Email:
Relationship: / Daytime Phone:

Please return the completed application to: GA CAPTA Panel & CJA Task Force Coordinator at:

Panel Assignment: / Start date: / Orientation:

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