Carroll County Mediation Process School Referral Form printable pdf download

Carroll County Mediation Process School Referral Form

Referral Date: _______________

School: _____________________________

Person Referring: __________________________ Your Position_______________________

Your Telephone: _______________________ Best time to contact you: __________________

yes  no  I need more information?

Would you participate in the conference if held?

Would the school be a good place for the conference? yes

 no

The parents of each student involved have been contacted and have given permission for student/parent

information to be shared with the program. (Note: Must have parent permission to refer the student.)

yes

 no

Information pertaining to the person(s) who caused the incident (list parent names if under age):

PARENT’S NAME

NAME

ADDRESS

PHONE

AGE

GENDER

RACE

NUMBER

Information pertaining to people who were affected by the incident:

NAME

ADDRESS

PHONE NUMBER

RELATIONSHIP TO

YOUTH

(Please complete the information on back of this sheet. Attach statement of charges or summary of

the incident.)

Carroll County Mediation Process School Referral Form