Does Offender admit responsibility? |
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Does the Offender agree to participate? |
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Do the Parents agree to participate? |
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Will this referral avoid at least 3 days suspension? |
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Person Making Referral |
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Title and School or Dept. |
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Your Email |
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Phone |
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Name of Respondent (offender) |
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Respondent Gender |
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School and Grade |
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Accused Of |
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Incident Date |
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Legal Guardian Name |
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Guardian Phone |
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Conseuquenses already in place - Please explain any punishments, suspension days, loss of activities, or any other consequence already in place for this particular incident |
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Alternative To |
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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 |
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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 |
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Victim Name(s) |
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Victim Parent Name(s) |
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Victim School and Grade |
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Victim Phone |
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Victim Email |
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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 |
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Affected Community Members - Please briefly explain impact to family members, neighbors and friends. please send other impacted community members to the impact statement |
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Paste Reports and Statements - Here, submit reports and other statements either in this box, or by Email or . Please be sure to indicate name of offender on all documents. |
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