Court-Ordered Community Service

Court-Ordered Community Service Application

Date
MM slash DD slash YYYY
Name*
First Last
Preferred pronoun
- they/them
- he/him
- she/her
Age*

Must be 16 or older to perform Community Service at Roice-Hurst Humane Society.
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Email*
Explain the charges that resulted in you needing court-ordered community services*
Total hours needed?*
Completion deadline*
Why would you like to complete your hours at Roice-Hurst?*
Do you have any special needs or need accommodations that we should be aware of or discuss with you?*
Emergency Contact
Name*
First Last
Relationship
Phone*
Criminal Record
Have you been convicted of or plead guilty to (also includes deferred judgment and no contest plea) a crime or been subjected to court martial? Do not include crimes for which public records are sealed or have been expunged.)*
- Yes
- No
If "yes," identify the nature of the offense, county and state where convicted, date of conviction, and sentence or fine imposed.
If you are presently charged with committing a criminal offense, identify nature of offense, county and state where charges are pending, and status of the charges.
- Yes, I want to stay connected with email newsletters and heartwarming stories from Roice-Hurst Humane Society!
*PLEASE NOTE: You will be required to sign a liability waiver before starting your community service
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