Author: Rebecca MacKenzie

COURT
MANDATED
SERVICE form

INTERCONGREGATION COMMUNITIES ASSOCIATION
11588 K-Tel Drive, Minnetonka, MN 55343
Volunteer Coordinator
Direct: 952.279.0288
Email: volunteer@icafoodshelf.org

We can only accept volunteers with non-violent offenses

Name		Date
Address		Phone
City / Zip
Email
Emergency Contact Name / Phone:

Birthdate

Name of the Offense
Brief Description of the Charge
Number of Service Hours Required
Date Hours Need to be Completed
Probation Officer’s Name
Probation Officer’s Address
Probation Officer’s Phone

Are you currently a client of ICA?
(Please circle your answer)

YES	NO

Statement of Understanding
I verify the information on this application to be true, complete and correct. I agree to support the mission of ICA.
(Please type name for signature)
X_______________________________________

Photo Release
I hereby agree to give ICA permission to use photos/videos that may include me for publication or to be kept on file for future publications.
(Please type name for signature)
X__________________________________