Juvenile Intervention Program Application Form

Has the juvenile ever been arrested or received a citation? If yes, please explain:

800 characters available

Has the juvenile ever been affiliated with any gang or tagger group? If yes, please explain:

800 characters available

Please provide details for each of the illicit activities checked above:

1600 characters available

Please describe any other negative behaviors displayed by the juvenile:

1600 characters available

If the juvenile is accepted into the program, they will receive a tour of the jails, learn about booking procedures, be given on-on-one counseling, and will be provided a free lunch on the day of the tour. Due to the nature of the program, the juvenile may feel some stress, anxiety, or other emotional discomfort. The following questions are asked to ensure their safety and the safety of the staff.

Does the juvenile have any medical conditions? If yes, please explain:

800 characters available

Does the juvenile have any prescribed medications? If yes, please explain:

800 characters available

Does the juvenile have any known allergies? If yes, please explain:

800 characters available

Does the juvenile have any history of, or is currently displaying, symptoms of depression or suicidal tendencies? If yes, please explain:

800 characters available

Has the juvenile ever been admitted to a mental health facility, either voluntarily or involuntarily? If yes, please explain:

800 characters available

Notice: To ensure that the program properly accommodates all enrollees, we may need to ask follow-up questions regarding your application. Please provide a phone number that we can call for questions and to deliver status updates.*

By submitting this form, you understand that:

• The provided information will be used to evaluate the juvenile's participation in the Juvenile Intervention Program.

• The submission of this form does not guarantee the juvenile's acceptance into said program.