Work Crew Registration Court Services Work Crew Registration Step 1 of 5 20% Name* First Middle Last Case Woker*SelectAngela DuursmaBrenda McWatersJose RegalJonathan LandonRyan BrundageDate of Birth* Month Day Year Address* Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Cell Phone*Work PhoneEmail Are you on probation?* Yes No Probation Officer Name* Are you on tether?* Yes No Are you on parole?* Yes No Parole Officer Name* EmploymentAre you employed?* Yes No Present Employer Name Number of Hours Per Week Type Full Time Part Time Current Work ScheduleList your normal work hours for each day of the week.MONTUESWEDTHURFRISATSUN EducationAre you currently attending school? Yes No Name of School Currently Attending Current School ScheduleList your normal school hours for each day of the week.MONTUESWEDTHURFRISATSUN In Case of EmergencyEmergency Contact Name* Emergency Contact Phone*Relation to Emergency Contact* Work Crew Assignment QuestionnaireTo help us with your Work Crew assignment, please answer the following questions:Number of Hours to be Completed* Have you done Work Crew before?* Yes No Did you finish the hours? Yes No Which days of the week would work best for doing your Work Crew hours?*Enter hours you are available.MONTUESWEDTHURFRISATSUNWhich shift(s) would you prefer? AM - 8:00am-12:00pm PM - 12:00pm - 4:00pm EVENING - 4:30pm-8:30pm Are there any days or shifts you are not able to report for Work Crew? Yes No If yes, specify which days or shifts and why: Do you have any medically documented physical limitations, restrictions or conditions that would interfere with your ability to do the Work Crew hours?* Yes No Describe* For which offense were you ordered to do Work Crew hours, please give details of the offense:*Have you had any prior convictions?* Yes No List criminal history below: List any misdemeanor convictions with dates below: List any felony convictions with dates below: CAPTCHACommentsThis field is for validation purposes and should be left unchanged.