Public Restitution/Community Service Request Form

Public Restitution/Community Service
Request Form

If you have been legally directed to complete public service hours and are interested in working with our department, please complete all information below. Your response to this form is confidental and your reason for needing service will not be shared amongst staff.

All requests are subject to a background check. Please know that some requests for service hours may be denied, depending on the nature of the offense. Please also note, if approved for service, that YOU are responsible for keeping a timesheet to track your hours and ensuring that Parks and Recreation staff signs off on them at the conclusion of a volunteer shift. It is NOT the responsibility of Parks and Recreation staff to track your hours for you.

Please allow at least two weeks' advance notice for our staff to conduct a background check and determine placement for service hours. We cannot guarantee placement on short notice.
Thank you for your understanding.
Contact Information
Your Name*

First NameLast Name
Your Email*
Please make sure this is an address you check regularly, should we need to send important information.
Contact Number*

Area CodePhone Number
Referral Information
Referral Source*

Monroe County Community CorrectionsIndiana University Student EthicsPersonal AttorneyOther
Contact Person from Referral Source*

First NameLast Name
Contact Person's Phone Number*

Area CodePhone Number
Contact Person's Email
Community Service Explanation*

Provide a brief explanation of offense resulting in need for public service hours.0/100
Service Hours Information
Number of Required Service Hours*
Date by Which Hours Must Be Completed*

MonthDayYear
Date
Indicate Availability*
Provide any other scheduling conflicts or ideal service times that may assist in coordinating your service.
Feel free to specify available work times within the weekdays/times of day listed above. Provide any other relevant information.

CITY OF BLOOMINGTON VOLUNTEER
BACKGROUND CHECK AUTHORIZATION

I hereby authorize the City of Bloomington to conduct criminal background checks to determine my eligibility for employment or continued employment.

I understand that the City is asking for my date of birth, previous names, and previous addresses only in order to conduct background checks and for no other reason.

By signing below, I hereby authorize the City of Bloomington to conduct background checks on me. I hereby release the City of Bloomington from any liability related to the procurement and/or disclosure of any information provided by me or obtained about me in connection with my application for employment with the City of Bloomington. I understand that any information gathered as a result of background checks will be kept confidential. I make this waiver knowingly and voluntarily.
Applicant's Signature*
Date of Birth*

MonthDayYear
Note: Your DOB, NOT today's date
Alternative name (if applicable)*
i.e. Have you ever gone by another name? If so, list above.
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Previous Address (if current address is less than one year)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
If you have any questions, please contact our volunteer coordinator, Emily Buuck, at parksvol@bloomington.in.gov.
- For Office Use Only -

Programs: Varies (for court-ordered service hours)

Supervisor: Emily Buuck
Should be Empty:

Public Restitution/Community Service Request Form

Contact Information

Referral Information

Service Hours Information

CITY OF BLOOMINGTON VOLUNTEER BACKGROUND CHECK AUTHORIZATION

Public Restitution/Community Service
Request Form

CITY OF BLOOMINGTON VOLUNTEER
BACKGROUND CHECK AUTHORIZATION