Loudoun County PRCS W.O.R.K. Program

W.O.R.K. Program Questionnaire


Information of the Person Requesting Community Service Hours

(mm/dd/yyyy)
calendar
Who will oversee/monitor your hours for court (Lawyer, Probation Officer, Court Officer, etc.)? - name and contact info.
(Loudoun circuit, Juvenile and Domestic Relations, Traffic, etc.)
(skills, training or certification such as typing, MS Office, past work experiences that may be useful in placement)
(Example: specific allergies, physical conditions, school suspension, no trespass orders, etc. Enter N/A if none)
(Do you have your own transportation or require your parents or other adults?)
PARENT/GUARDIAN SECTION

If you are under 18 this information is REQUIRED.

Parent/Guardian #1 - Authorized to Pick Up Youth

Parent/Guardian #2 - Authorized to Pick Up Youth (Optional)

Non-Parent/Guardian Emergency Contacts

Adults (18 years of age or older) MUST list two other adults, within 30 miles of the site, authorized to pick up the youth participant. This could be a family friend, neighbor, relative, etc. Note: if parents and emergency contacts are unable to be reached PRCS MUST call VA Child Protective Services (CPS) in some emergency cases. Please be sure we have complete and accurate information.

Emergency Contact #1

Emergency Contact #2

The nature and scope of the activity listed above have been fully explained to me by the Parks, Recreation and Community Services Staff and I understand that there may be risks and dangers associated with this activity. I also understand that each participant has the responsibility to exercise due care in the performance of the activity for their own safety and of the other participants and will abide by the safety rules and regulations established for the activity. In consideration of the participant being permitted to enroll and partake in this activity,

I agree to assume all risks to my (child's) person or property, including transportation, incidental to such participation. I do hereby waive, release, absolve, indemnify and agree to hold harmless, the County of Loudoun, the Loudoun County Department of Parks, Recreation and Community Services and any Employees or Volunteers thereof, against any injury to person or property arising out of this registration.

I agree to Loudoun County Parks, Recreation, and Community Services's Zero Tolerance Policy. Use or presence of Tobacco products, alcohol, drugs, or fireworks is prohibited. The use or threat of use of weapons is prohibited. Theft, shoplifting, any violent behavior, or destruction of property will result in immediate dismissal from the program. Parent/Guardians will be expected to provide immediate transportation from the program in the event of dismissal.

I give permission for the Loudoun County Parks, Recreation and Community Services staff to obtain medical treatment for the above participant in the event of illness or injury if I cannot be contacted.

Release and Waiver of Liability

This release applies to the Loudoun County Government (hereafter referred to as the “County”) and its officers, employees, and agents in accordance with the terms set forth below. The Volunteer signing below (or a parent on behalf of his/her minor child) understands that the scope of his/her relationship with the County is limited to that of a volunteer and no compensation is expected or will be provided in return for services performed by the Volunteer; that the County will not provide any benefits traditionally associated with employment to Volunteer; and that Volunteer is responsible for his/her own insurance coverage in the event of personal injury or illness as a result of Volunteer’s services to the County.

1. Waiver and Release: I, the Volunteer or parent signing below, release and forever discharge and hold harmless the County and its successors and assigns from any and all liability, claims, and demands of whatever kind or nature, either in law or equity, which arise or may hereafter arise from the services I provide to the County. I understand and acknowledge that this Release discharges the County from any liability or claim that I may have against the County with respect to bodily injury, personal injury, illness, death, or property damage that may result from the services I provide to the County or occurring while I am providing volunteer services.

2. Insurance: I understand that the County does not assume any responsibility for providing me with financial or other assistance, including but not limited to medical, health, or disability benefits or insurance. In the event of injury to me and/or I incur any medical expenses as a result of my volunteer services, I expressly waive any claim for compensation or liability on the part of the County beyond what may be offered freely by the County.

3. Medical Treatment: I hereby release and forever discharge the County from any claim whatsoever that arises or may hereafter arise on account of any first-aid treatment or other medical services received in connection with an emergency during my tenure as a volunteer with the County.

4. Volunteer Policies: I agree to abide by all policies and procedures discussed during volunteer orientation and training.

5. Photographic Release: I grant and convey to the County all right, title, and interests in any and all photographs, images, video, or audio recordings of me or my likeness or voice made by the County in connection with the volunteer services provided by me to the County, which may be used by the County in its marketing or promotional materials.

6. Other: As a volunteer, I expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws of the Commonwealth of Virginia and that this Release shall be governed by and interpreted in accordance with the laws of the Commonwealth of Virginia. I agree that in the event that any clause or provision of this Release is deemed invalid, the enforceability of the remaining provisions of this Release shall not be affected.

Loudoun County W.O.R.K. Program Rules: PLEASE READ CAREFULLY!
  1. I agree to show up for community service when scheduled. If I do not show up at the prescribed time or date, I must contact staff/supervisors at my assigned facility and inform them of the absence (I.e. family emergency, illness). More than two unexcused absences (no shows) may result in termination from the W.O.R.K. Program.
  2. I agree to fully cooperate with all PRCS staff or their designees, follow all rules and instructions, and complete all assignments or tasks successfully. I agree to comply with all laws; and act in a safe, courteous and responsible manner at all times. Failure to comply with these guidelines, or if I become uncooperative in any way, I will be automatically terminated from the W.O.R.K. Program. My probation officer will also be notified immediately as well.
  3. I agree to wear clothing that is both work appropriate, and appropriate to wear around the general public.


I am the participant, and I certify that the data entered are true and I agree to the program rules.


I am the parent/Guardian, and I certify that the data entered are true and I agree to the policy above.


I am the adult, and I certify that the data entered are true and I agree to the policy above.

**Questions or technical difficulties please email Loudoun County W.O.R.K Program manager Mr.Stuart Younkin, Stuart.Younkin@Loudoun.gov