INTERSTATE COMPACT FOR JUVENILES 

FORM VII 

    OUT OF STATE TRAVEL PERMIT AND AGREEMENT TO RETURN 

 VACATION/VISIT ONLY 

 VISIT FOR TESTING RESIDENCE  

 PLACEMENT IN RESIDENTIAL FACILITY 

(Receiving State) 

(Sending State) 

From: 

(Name, Title) 

(Agency/Department) 

(Phone #) 

(Juvenile’s Name) 

(DOB) 

 (Race/Sex) 

*If known:   *Ht.

*Wt.

*Eye Color:

*Hair Color:

(Court/Agency #) 

(Legal Status) 

Permission is granted to the above-named juvenile to visit the State of 

from 

During which time the juvenile 
will be staying with/at: 

(Date) 

until 

(Date) 

(Name/Facility) 

(Relationship) 

(City) 

(State) 

(Zip) 

(Phone #) 

To: 

From: 

Re: 

(Offense) 

Current Residence 

Name: 

Relationship: 

Address: 

Phone: 

at 

(Full Address) 

Reason for Visit: 

Special 
Instructions/Other 
Comments: 

Juvenile’s Statement of Understanding 
I,  

           

recognize I am under the legal custody/jurisdiction or supervision of the State of 
I  hereby agree to comply with the rules and regulations of the Interstate Compact 

      . 

for Juveniles and the laws of the sending and receiving state including the above conditions and instructions.  I  
understand my failure to comply with these conditions may result in a warrant or requisition being issued for my 
arrest or return. 
 I have read, or  

 have had read and explained to me, the Statement of Understanding. 

Witnessed by: 

(Signature of Caseworker or Probation/Parole Officer) 

Approved by: 

ICJ Travel Permit  |  Rev. 11-14-16

(Signature of Supervisor) 

(Juvenile’s Signature) 

(Date) 

(Title) 

(Title) 

(Date) 

(Date)