Community Service Provider Application Agreement

Agency Name*

Contact Person*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Phone*

Website

Area of Town*

Are you currently, or have you previously provided, community service opportunities to defendants from the Austin Municipal Court? *

Yes No

Please list all duties you would expect a community service worker to perform:

Will you require a worker to use power tool and/or chemicals? *

Yes No

List and provide an explanation of how tools and/or chemicals would be used:

Austin Municipal Court does not assign adult defendants to a work site. Defendants are provided a list of approved sites to choose from. In addition, we do not have the ability to screen adult or juvenile defendants for offenses they may have been convicted of in other courts and/or jurisdictions. As such, are you willing to accept a defendant’s self - report as it relates to criminal history? *

Yes No

What are your minimum age requirements?*

If you were to accept youth (ages 10-17), under what conditions would you accept them?

Do you require a training period?*

Yes No

What are the requirements?

If we refer community service workers to you, do you agree to track and submit the number of hours of community service each worker performs? *

Yes No

What are the days and hours that workers can be utilized at your organization?*

(Please note that the days/times approved are publicly disseminated. Please alert the court to any changes immediately.)

Please indicate what type of organization your agency is (check all that apply)*

Please indicate what type of organization your agency is (check all that apply)
	Yes	No
Government entity	Please indicate what type of organization your agency is (check all that apply): Government entity (Yes)	Government entity (No)
Educational Institution	Educational Institution (Yes)	Educational Institution (No)
Non-Profit or another organization that provides services to the general public that enhance social welfare and the general well- being of the community	Non-Profit or another organization that provides services to the general public that enhance social welfare and the general well- being of the community (Yes)	Non-Profit or another organization that provides services to the general public that enhance social welfare and the general well- being of the community (No)
Do you have IRS 5Ol(C) (3) designation? If yes, please attach a copy.	Do you have IRS 5Ol(C) (3) designation? If yes, please attach a copy. (Yes)	Do you have IRS 5Ol(C) (3) designation? If yes, please attach a copy. (No)

If applicable, please upload a copy of your IRS 5Ol(C) (3) designation No File Chosen

File uploads may not work on some mobile devices.

What services do you provide?*

Do you agree to supervise any defendant referred to you in the performance of the work assigned?*

Yes No

Please indicate how defendants will be supervised and whether supervision will be conducted in person or remotely.

Do you maintain workers compensation and liability insurance?*

Yes No

Please attach copies No File Chosen

File uploads may not work on some mobile devices.

You must attach a copy of your organization's Volunteer Agreement to include a waiver of liability. The Agreement must be provided to all Community Service workers. Your organization must maintain a copy of the Agreement as signed by each worker. Austin Municipal Court reserves the right to request copies of signed agreements for auditing purposes. No File Chosen

File uploads may not work on some mobile devices.

Does your agency have staff available to communicate to a community service worker in Spanish?*

Yes No

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finger pad or mouse text field (compatible with screen readers)

I attest that the information provided is true and correct to the best of my knowledge. I have read and understand the guidelines listed above and understand the Court may conduct unannounced site visits to ensure information submitted on this form is accurate and representative of the nature of the work being performed. *

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Name*

First Name

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Last Name

City of Austin Municipal Court

Community Service Provider Application Agreement