SÉAN R. RYAN ADULT PROBATION AND PAROLE DEPARTMENT Chief Adult Probation & Parole Officer Court of Common Pleas of Bucks County SEVENTH JUDICIAL DISTRICT OF PENNSYLVANIA SUSAN DEVLIN SCOTT President Judge Community Service Program NAME: _________________________ ADDRESS: _________________________ DOB: _________________________ _________________________ TELEPHONE: (H) __________________ (W) __________________ (C) __________________ 1. Do you suffer from any health problems/handicaps/allergies? _________________________________ If yes, describe: (include doctor, medications, etc.) _________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ 2. Are you presently covered by a health care plan? ___________________________________________ If yes, explain: ______________________________________________________________________ __________________________________________________________________________________ 3. Do you have any skills/interests you would like to use in your placement? _______________________ __________________________________________________________________________________ __________________________________________________________________________________ COMMUNITY SERVICE PROGRAM AGREEMENT AND LIABILITY WAIVER And now, intended to be legally bound thereby, ____________________ (offender) agrees to provide community services assigned by the Bucks County Adult Probation and Parole Department (BCAPPD) in the amount of _________ hours as determined by Judge ____________________ on ____________________ (date). Community Service hours are to be completed by ____________________ (maximum date or court ordered date). The offender understands that he/she is under the supervision of the BCAPPD, is covered to some extent by their medical insurance plan and will not receive compensation for services performed. The offender agrees to give Community Service Program (CSP) staff permission to release information about the offender to participating placement agencies. The offender will act in an appropriate, courteous and reliable manner while at the work site. Usage of alcohol or illegal drugs will not be tolerated. Offender will report as scheduled and on time and will supply the necessary information to explain any excused absence. The offender must make immediate phone contact whenever unable to keep a scheduled appointment or work assignment and must reschedule. Failure to follow any of the above rules can result in a violation of probation/parole hearing as determined by the BCAPPD. The offender will not make any claim against the CSP, BCAPPD, placement agency, and/or Bucks County Court of Common Pleas and these agencies are absolved of any and all responsibilities for damages or injury to persons or property or liabilities incurred with placement of its offenders. I have read the above rules, conditions, and waivers and by signing I understand and agree to the above. ___________________________________ Witness ___________________________________ Date White – Offender Administrative Office: 55 East Court Street, 7th Floor Bucks County Courthouse Doylestown, PA 18901 Phone: (215) 348-6634 Fax: (215) 348-6691 ___________________________________ Probationer/Parole e ___________________________________ Social Security Numbe r Yellow – Case File Central Bucks Unit: 55 East Court Street, 6th Floor Bucks County Courthouse Doylestown, PA 18901 Phone: (215) 348-6102 Fax: (215) 348-6253 Pink – CSP Coordinator Lower Bucks Units: 600 Louis Drive, Suite 100 Warminster, PA 18974 Phone: (215) 442-0209 Fax: (215) 442-0693 American LegalNet, Inc. www.FormsWorkFlow.com Upper Bucks Unit: 261 California Drive, Suite 3 Government Services Center Quakertown, PA 18951 Phone: (215) 529-7081 Fax: (215) 529-7138