Volunteer Responsibilities Statement

By submitting this form, you agree that you understand when you are serving at a volunteer station, you are responsible for your own food, water, transportation, medication, sun block, hat, gloves, cash, and any other appropriate supplies needed in the performance of this community service assignment. It is also your responsibility to call the agency to determine what is needed for the assignment before showing up to work there.

Neither the Five County Community Action Partnership nor the non-profit agency to which you may be assigned are responsible to provide these items for your Court-Ordered Community Service.

Name

First Name

Last Name

Date of Birth

YYYY

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Court Information

Court Name

The court your community service hours were ordered by

Required Completion Date

YYYY

Required Number of Hours

Case Number

Please describe the circumstances which caused you to be court-ordered to do community service:

Demographics

Highest Level of Education

6th Grade or Under

Some High School

High School Graduate

College Graduate

Post Graduate

Select One

Marital Status

What languages do you speak?

Are you currently homeless (living in a shelter, fleeing domestic abuse, or living in an environment not intended for human habitation)?

Do you have transportation?

Experience and Availability

Please list the days/times you are available to work toward your community service (leave blank if unsure):

Do you have any Disabilities that would limit your work?

If you marked "yes" for the above question, please explain your limits so that we can help find you a suitable place to complete your hours:

Please list work experience that may be relevant to community service hours:

Volunteer Responsibilities Statement

Connect

Programs

Five County AOG Community Action Partnership