Does Offender admit responsibility?

Does the Offender agree to participate?

Do the Parents agree to participate?

Will this referral avoid at least 3 days suspension?

Is this case appropriate for Peer Court?

Person Making Referral

Title and School or Dept.

Your Email

Phone

Name of Respondent (offender)

Respondent Gender

Date of Birth

Street Address

Zip Code

School and Grade

Phone Number

Accused Of

Incident Date

Conseuquenses already in place - Please explain any punishments, suspension days, loss of activities, or any other consequence already in place for this particular incident

Alternative To

Explain - For this particular case, please explain how you are using peer court as an alternative to arrest, suspension, expulsion, juvenile court or a combination of these sanctions

Legal Guardian Name

Guardian Phone

Respondent Support People - Please list names and numbers for case managers, staff members or other people who are already supporting the respondent in school or the community

Victim Name(s)

Victim Parent Name(s)

Victim School and Grade

Victim Phone

Victim Email

Victim Address w ZIP

Victim Impact - Please briefly explain impact to direct victims in this case, then please proceed to the Victim Impact Statement to make a more complete statement

Affected Community Members - Please briefly explain impact to family members, neighbors and friends. please send other impacted community members to the impact statement

Paste (or send) Reports and Statements - Here, submit reports and other statements either in this box, or by a separate statement by FAX at 415-865-2538, or by EMAIL to: Nicole@peercourt.org. Please be sure to indicate name of offender on all documents