Community Services Intake Form - Boulder County Community Justice Services
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Boulder County
COMMUNITY JUSTICE SERVICES
Community Service Intake Form
The Community Service Fee is $100 to cover administrative costs and supplemental insurance. This fee is in
addition to the fines and costs you may have paid to the Courts (Clerk’s office).
Date: _____________________________________
FULL NAME:___________________________________________________________________________
Last
First
Middle
Other Names Used
Email Address
Mailing
Address:_________________________________________________________________________________________________
Street (Apt. #)
City
State
Zip
Home Phone: _________________________ Work Phone: __________________________ Cell Phone: ___________________
Date of Birth: ________________________
Male
Female
Social Security #: __________________________
Ethnicity:
White
Hispanic/Latino
African American
Native American
Asian
Other _______________
Do you speak English?
Yes
No
What is your primary language: _________________________________________
In case of emergency, who should be contacted?
____________________________________________________________________________________________________________________
Name
Relationship
____________________________________________________________________________________________________________________
Address
____________________________________________________________________________________________________________________
Phone Number(s)
# Of Dependents: ___________
Marital Status:
Single
Married
Divorced
Widowed
Last school grade completed:_______
GED:
Yes/ Date Recvd.: _______
No
Current Student:
Yes
No
If student, what school are you attending?
___________________________________________________________________
Present employer:_______________________________________ City: _______________________ How long?:_________
Occupation/type of work: ______________________Days off : M
T
W
Th
F
Sat
Sun
Days
Eves
Varies
Original Charge(s): _______________________________________________________________________________________
Were you under the influence of alcohol and/or drugs at the time of the offense?
Yes
No
Alcohol level: ___________
Prior Arrests (dates/where):
____________________________________________________________________________________________________
Have you ever been arrested for a Sex Offense?
Yes
No If yes, what? ______________________________________
Are you a registered sex offender?
Yes
No
Any limitations that would affect your placement for community service:
Yes
No
If yes, what (ex. no heavy lifting, etc.):
____________________________________________________________________
Method of transportation (ex. bus, bike,):
______________ Skills/Interests: _______________________________________
Previous volunteer experience:
___________________________________________________________________________
Have you performed court ordered community service in the past?
Yes
No Where: _____________________________
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Parent category: Letters