Community Service Application
Charges related to the hours required:
Details (optional):
Number of hours needed:
Date to be Completed:
-
Month
-
Day
Year
Date
Court Worker/Probation Officer Name:
Court Worker/Probation Officer Number:
Format: (000) 000-0000.
Name:
First Name
Last Name
Date:
-
Month
-
Day
Year
Date
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Telephone:
Format: (000) 000-0000.
Email:
example@example.com
Emergency contact: Name
First Name
Last Name
Emergency Contact Phone Number
Format: (000) 000-0000.
Can you work independently?
Yes
No
Days available:
Mon
Tues
Wed
Thurs
Fri
Sat
Times available:
Morning
Afternoon
Evening
Kitchen
Kitchen
Valley Mission Truck (picking up donations)
Thrift Store
Other
Special skills you have or equipment you have used:
Have you ever been convicted of a felony?
Yes
No
If yes, please explain:
I give Valley Mission, Inc. the right to check my background and release from all liability or responsibility all persons or companies supplying information. If applicable, I give Valley Mission, Inc. permission to contact my Probation Officer.
CONFIDENTIALITY AGREEMENT:
I promise I will not divulge any information that I may hear or see concerning any client, any member of staff, or any volunteer of the Valley Mission during my work at Valley Mission, Inc.
Signature
Date
-
Month
-
Day
Year
Date
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Submit
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