Juvenile Community Work Service Agreement Form
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1DAKOTA COUNTY
JUVENILE COMMUNITY WORK SERVICE AGREEMENT
PETITION#:____________________________ OFFENSE:__________________________________________ P.O.____ ______________
YOU HAVE BEEN ORDERED TO COMPLETE ___________ HOURS OF COMMUNITY WORK SERVICE BY ____________________________
Contact a non-profit or charitable organization and set up a work schedule within 14 days. Schools and
churches are good to check with. If you are under the age of 13 or cannot find a worksite contact the
CWS coordinator at 952-891-7298. Make sure your hours are being logged daily and verified.
You may have an option to pay a fine in lieu of performing CWS. The rate is $7.00 per hour for each hour
of CWS ordered. Call the CWS Coordinator to receive approval and necessary forms.
At the worksite
Follow the agreed upon work schedule and abide by worksite rules and expectations.
Do not be under the influence of alcohol, non-prescription drugs or use tobacco while at the worksite.
Contact CWS Coordinator if there is any reason you will miss your deadline or not complete your hours.
Ensure completed timesheet is submitted to the CWS coordinator before the completion deadline.
It is your responsibility to ensure that the worksite contact person completes and submits the timesheet
to the CWS Coordinator before the completion deadline.
YOU MUST EITHER COMPLETE & VERIFY YOUR CWS OR PAY A FINE BY THE DUE DATE GIVEN.
FAILURE TO COMPLY CAN RESULT IN FURTHER COURT ACTION.
I agree to and understand the above rules. If I fail to follow the rules, I can be terminated from my worksite and/or the
community work service program and be returned to the court for further sanctions.
I understand that if I am injured while performing work service I must notify my worksite supervisor immediately. I
also understand that my medical insurance must be used to pay for medical costs. If I do not have medical
insurance or if I have costs that are not covered, I must contact my CWS coordinator within 30 days of my injury to
file a claim. If I do not, I will assume full responsibility for my medical costs. Any follow-up care for my injury must
be pre-approved by Dakota County in order for those expenses to be paid.
Print Name: _______________________________________ DOB: _____________ Phone:_________________________
Address:_________________________________________________ City,State,Zip: _______________________________
Parent’s Work Phone: _________________________________ Additional Daytime Phone:_________________________
Email
Address_________________________________________________________________________________________
Client’s signature: ______________________________________________________
Date:_______________________
Parent’s signature: ______________________________________________________
Date:_______________________
Contact Information:
Dakota County Community Corrections
Attn: Community Work Service
1 Mendota Rd
West St Paul MN 55118
Phone 952-891-7298
Fax 651-554-6070
Email: CcJuvCWS@CO.Dakota.MN.US
O:\CWS\Forms\Juv-CWS Agreement – English 1-28-13
OnBase Index: 65J CWS
Agreement
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