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 is overseeing/monitoring your hours for court ? (provide name and contact information)
(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.

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