REFERRAL TO THE SHASTA COUNTY YOUTH/PEER COURT
Name of Minor: _______________________________________Date of Birth:__________
Name of Parents/Guardians____________________________________________________
(please circle)
Address: __________________________________________________________________
Telephone: Home:_______________Work: _____________________ Cell: ___________
Age: ______ Grade: _______ School:__________________________________________
Number in Household: _________ Female Head of Household ¨Yes ¨ No
FOR GRANT PURPOSES ONLY please state annual family income: $__________
Ethnicity: Hispanic ________ Non-Hispanic _______
Race: (Check any that apply)
_____ American Indian or Alaska Native _____ Asian
_____ Black or African American _____ Native Hawaiian or Pacific Islander
_____ White _____ Hispanic
_____ Other
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Offense: ___________________________ Code: ________________________
Amount of Restitution Owed: ____________ Youth of Incarcerated Parent ¨YES ¨NO
Restrictions on type of work minor can perform: _____________________________________
I understand the potential dispositions to be assigned to my son/daughter may include the following:
_____ Essays (not to exceed 1000 words)
_____ Written or face-to-face apology
_____ Jury duty
_____ Community Service (not to exceed 40 hours)
_____ Juvenile Court Work Days (7:30 am- 3:30 pm – not to exceed 5 days per violation)
_____ Anger Management, Victim Awareness, Shoplifting, Drug & Alcohol, & other classes
_____ Coroner’s Tour
I agree to have my case by the Shasta County Youth/Peer Court. In agreeing to this, I authorize the release of all information pertaining to my case to the Shasta County Youth/Peer Court. This may include the police report, school report and/or school records. Information obtained will be used in determining the appropriate disposition of my case and for the determination of other services.
Date: _________________ Signature of minor: ________________________________________
Date: __________________ Signature of parent/legal guardian:____________________________