Personal Data Form For Office Use Only Extension or Regranted Service Extension Regranted Service Today's Date * Last Name * First Name * Middle Name Address * Address Address Address Address Address State AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Address Home Phone * Cell Phone * Email * Date of Birth * Age * Sex * Male Female Other Emergency Contact Name * Relationship * EC Phone * Judge * County * Court Division # Case # Termination Date * Probation Officer Name * PO Email Address * Please list any skills or interests * Please list any physical limitations How many hours at a time are you comfortable standing Can you lift heavy items? * Yes No Do you have a valid driver's license? * Yes No Any suggestions or requests for where you would like to complete your UPS * Useful Public Service Agreement 1) You MUST choose a Non-profit or Government organization to complete your hours at. 2) The cost of the program is as follows: 1-16 hours ....... $75.00 17 + hours ...... $120.00 Juvenile Case ..... $75.00 Extension Fee ..... $50.00 The fee must be paid prior to placement. No clients are placed without payment. 3) You can choose an agency that is not specifically on our list. However, the agency MUST be approved by RMS and the fee still applies. Credit for any hours completed at an agency that is not approved by RMS prior to completing them will not be granted. 4) Completed hours are due on the day specified by Court or the Case Manager with NO exceptions. If an extension is needed it MUST be cleared by the RMS case manager NOT, the agency that you choose to complete your work at. Extensions will not be granted for cases that are scheduled to return to court for sentencing. 5) It is the client’s responsibility to return verified hours to RMS before the scheduled due date. 6) If you are injured while on a job site, RMS will not be responsible for your medical care. 7) Release. As a material consideration for being permitted by RMS, to participate in their management system, I hereby agree on behalf of myself, my heirs, personal or legal representatives or any other person or legal representatives or any other person and or entity claiming through me to indemnify and hold RMS, its owners or employees harmless from any and all damage, injury or death however caused which occurs during and after my period of management. I forever release RMS, its owners, employees, and any of its affiliated organizations from any and all liability arising out of or connected in any way to my participation in their offender management. Further, I release RMS from any and all liability to the extent that RMS monitors any Useful Public Service imposed by Court sentence, and that my participation in any such Useful Public Service is voluntary and affords RMS the protections enumerated in section 16-11-701 C.R.S. as amended. Client Initial * 8) Knowing and Voluntary Execution. I have carefully read this agreement and fully understand its contents. I am aware that this is a binding release of liability in favor of RMS, and/or its owners, employees, or affiliated organizations. I sign this release of my own free will. Client Initial * 9) Verification that you completed Hours are due back to RMS by 4pm on I have read the above information and have had all Rules explained to me by RMS staff. I understand that failure to follow any of these Rules may result in revocation and my return to Court. Repeated refusal to meet these, or any other requirements, may result in my return to Court. Your Signature * signature keyboard Clear Date Signed * reCAPTCHA If you are human, leave this field blank. Submit Δ
