THIRD DISTRICT  JUVENILE COURT WORK PROGRAM REFERRAL 

Please complete all information accurately.  Incomplete referrals will not be accepted..   

ourt Case #: _____________ Date of Birth: _________ Male               Female                 

uvenile=s Name:________________________________________________________________ 

treet Address: _________________________________________________________________ 

ity:_________________ Zip Code:___________Phone #: ______________________   

nterpreter needed? If so what language?                                     

CHOOL INFORMATION 

Are you attending school? __________ School Name: __________________________________ 
School Begins at what hour? ____________________________________ 
School is Dismissed at what hour?  ____________________________________ 

ARENT/GUARDIAN INFORMATION 

Parents/ Guardians Name: ________________________________________________________ 
Father=s work # _______________________________   Father=s Cell #  ___________________ 
Mother=s work # ______________________________   Mother=s Cell # ___________________ 

nterpreter needed? If so what language?                                     

mergency Contact if parents are unavailable:                                   Phone #:                           

elationship to Juvenile: ________________________________________________________ 

COURT OBLIGATIONS/ORDERS:  

ESTITUTION OWED                              DUE DATE                                        

ORK HOURS _____________________ DUE DATE ___________________ 

outh may not work off money owed to Crime Victims Reparations or insurance companies. 

O-DEFENDANTS and/or NO CONTACT ORDERS: 

______________________________________________________________________________ 

TATE SUPERVISION: 

YES [   ] 

NO [  ] 

PSRA Date                       Check One  High            Mod              Low                  

PECIAL NEEDS OF YOUTH 

___________________________________________________ 
i.e.  (Physical or mental medical condition, medication taken, etc. . .)  

ourt/Agency Workers Name: ____________________________ Phone # ______________ 

**PLEASE HAVE PARENT/GUARDIAN COMPLETE THE NEXT PAGE*** 

 

 

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Youth=s Social Security Number:                                            
I/We understand that if a valid Social Security Number is not provided above and my child 
requires medical attention while on the work program, my child might not be covered by 
Workman=s Compensation. 

 

Release of Liability 
We, the parent (s) or legal guardian (s) of ____________________________________________ 
agree to allow said juvenile to participate in all work programs sponsored by the Third District 
Juvenile Court.  We release the Third District Juvenile Court and all participating work sites 
from any and all liability claims.  Furthermore, we authorize the personnel of Juvenile Court to 
take our child to medical facilities for care should the need arise. 

edia Release 

Checking agree under Media Release allows youth to be photographed and/or interviewed by the 
 media while participating on the Court=s Work Program. 
Agree __________ 
Disagree ________ 

earch and Seizure 

Juveniles will be subject to searches upon reporting for work, upon entering a vehicle, or at the 
discretion of Court personnel.  By participating in this program the youth and parents/guardians 
consent to searches and seizures conducted by Juvenile Court personnel.   

lternative Transportation Permission Slip 

As parents / guardians we give Third District Juvenile Court Permission to allow our child to 
(check all that apply): 
__________ Ride the UTA bus, Trax, bicycle or walk home from the 7th West Work Program     
                        building or from work sites. The work sites vary daily.  If the site is near the 
youths                        home we will allow them to leave from the site.  If child rides the UTA bus 
or trax,                         parents need to provide bus money and inform youth of the correct bus 
route and                            schedule. 
__________ To be picked up at the end of the work shift at the 7th West Work Program building. 
                     If the youth is not picked up by 8:15pm during the week or 3:45pm on Saturday       
                       they will be transported to the Juvenile Receiving Center at 177 W Price 
Av.3610S. 
                     If there is anyone that is specifically not allowed to pick up your youth notify us      
                        ahead of time. 

/we have read and understand the above statements regarding Social Security Number, 
Release of Liability, Media Release, Search and Seizure, and Transportation. Further, I 
understand that it is my responsibility to notify the court work program of any medical 
condition which could affect this youth=s health or behavior prior to enrollment in the 
Work Program. 

arent/Guardian: ________________________________________________  Date:_________ 

uvenile:______________________________________________________    Date: _________ 
Please return form to: Third District Juvenile Court, W26 Matheson Courthouse, 450 S. 
State or mail to PO Box 140431, SLC  UT 84114-0431  ATT: Work Program.    Questions 
call Nicole Keith 238-7723 or Shane Kibler 238-5987 

 

 
 

Updated April 4, 2007 

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