Step 1 of 10 10% TAC-OLY PAP REGULARPermitted Activity PlanAmend Submitted Activity PlanEmergency Medical ActivityIf you are submitting your request within 24 hours of the event you must submit this form AND call our office at:253-238-0645If this is a medical emergency please call 253-238-0645 and just go and please submit the form when you have a chance. Name as it appears on ID or Court Order First Last Cell PhoneYour Email Court/Probation Permitted Activity PlanDate of the Activity MM slash DD slash YYYY Permitted ActivityEmployment (if "under the table" work, must be permitted by court)Court Hearing. Proof RequiredProbation Meeting. Proof RequiredAA/NA MEETINGS. Proof RequiredTreatment/Assessments Proof Required.On-Campus School. Proof RequiredReligious Activity. Proof RequiredMedical/Dental Appointment (Must Specify)Grocery 2hrs max 1x weekly. Proof RequiredOther. Must explain and Proof RequiredPermitted ActivityEmployment (if "under the table" work, must be permitted by court)Court Hearing. Proof RequiredProbation Meeting. Proof RequiredAA/NA MEETINGS. Proof RequiredTreatment/Assessments Proof Required.On-Campus School. Proof RequiredReligious Activity. Proof RequiredMedical/Dental Appointment Proof RequiredGrocery 2hrs max 1x weekly. Proof RequiredOther. Must explain and Proof RequiredPermitted ActivityEmployment (if "under the table" work, must be permitted by court)Court Hearing. Proof RequiredProbation Meeting. Proof RequiredAA/NA MEETINGS. Proof RequiredTreatment/Assessments Proof Required.On-Campus School. Proof RequiredReligious Activity. Proof RequiredMedical/Dental Appointment (Must Specify)Grocery 2hrs max 1x weekly. Proof RequiredOther. Must explain and Proof RequiredIf you selected other please explain*Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Activity Start : Hours Minutes AM PM AM/PM Activity End : AM PM AM/PM Time you Leave Home : Hours Minutes AM PM AM/PM Time you Return Home : Hours Minutes AM PM AM/PM 1. Do you need to create another activity? Yes No ActivityDay/Date MM slash DD slash YYYY ActivityHomeWorkBusiness OwnerTreatmentCounselingAttorneyOther Court Ordered Activities (Must Specify Below)UA / LabMedical AppointmentDNA TestingSchoolOther (Must Specify)ActivityHomeWorkChurchActivityHomeWorkIf you selected other please explainAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Activity Start : Hours Minutes AM PM AM/PM Activity End : Hours Minutes AM PM AM/PM Leave Home : AM PM AM/PM Return Home : AM PM AM/PM 2. Do you need to create another activity? Yes No Day/Date MM slash DD slash YYYY ActivityHomeWorkBusiness OwnerTreatmentCounselingAttorneyOther Court Ordered Activities (Must Specify Below)UA / LabMedical AppointmentDNA TestingSchoolOther (Must Specify)ActivityHomeWorkChurchActivityHomeWorkIf you selected other please explainAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Activity Start : AM PM AM/PM Activity End : AM PM AM/PM Leave Home : AM PM AM/PM Return Home : AM PM AM/PM 3. Do you need to create another activity? Yes No Day/Date MM slash DD slash YYYY ActivityHomeWorkBusiness OwnerTreatmentCounselingAttorneyOther Court Ordered Activities (Must Specify Below)UA / LabMedical AppointmentDNA TestingSchoolOther (Must Specify)ActivityHomeWorkChurchActivityHomeWorkIf you selected other please explainAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Activity Start : AM PM AM/PM Activity End : AM PM AM/PM Leave Home : AM PM AM/PM Return Home : AM PM AM/PM 4. Do you need to create another activity? Yes No Day/Date MM slash DD slash YYYY ActivityHomeWorkBusiness OwnerTreatmentCounselingAttorneyOther Court Ordered Activities (Must Specify Below)UA / LabMedical AppointmentDNA TestingSchoolOther (Must Specify)ActivityHomeWorkChurchActivityHomeWorkIf you selected other please explainAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Activity Start : AM PM AM/PM Activity End : AM PM AM/PM Leave Home : AM PM AM/PM Return Home : AM PM AM/PM 5. Do you need to create another activity? Yes No Day/Date MM slash DD slash YYYY ActivityHomeWorkBusiness OwnerTreatmentCounselingAttorneyOther Court Ordered Activities (Must Specify Below)UA / LabMedical AppointmentDNA TestingSchoolOther (Must Specify)ActivityHomeWorkChurchActivityHomeWorkIf you selected other please explainAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Activity Start : AM PM AM/PM Activity End : AM PM AM/PM Leave Home : AM PM AM/PM Return Home : AM PM AM/PM 6. Do you need to create another activity? Yes No Day/Date MM slash DD slash YYYY ActivityHomeWorkBusiness OwnerTreatmentCounselingAttorneyOther Court Ordered Activities (Must Specify Below)UA / LabMedical AppointmentDNA TestingSchoolOther (Must Specify)ActivityHomeWorkChurchActivityHomeWorkIf you selected other please explainAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Activity Start : AM PM AM/PM Activity End : AM PM AM/PM Leave Home : AM PM AM/PM Return Home : AM PM AM/PM 7. Do you need to create another activity? Yes No Day/Date MM slash DD slash YYYY ActivityHomeWorkBusiness OwnerTreatmentCounselingAttorneyOther Court Ordered Activities (Must Specify Below)UA / LabMedical AppointmentDNA TestingSchoolOther (Must Specify)ActivityHomeWorkChurchActivityHomeWorkIf you selected other please explainAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Activity Start : AM PM AM/PM Activity End : AM PM AM/PM Leave Home : AM PM AM/PM Return Home : AM PM AM/PM I certify that this schedule request complies with the rules and guidelines of my program as ordered by the Referring Authority. Validation of this request is incumbent upon me to disclose and provide copies of documents, receipts, payroll time sheets, confirmation of medical appointments and all court sanctioned activities. I understand that failure to provide this information timely and legibly will result in program violation and possible removal from program.Signature*Date* MM slash DD slash YYYY NumberNumberNameThis field is for validation purposes and should be left unchanged.
