MSL Schedule

Youth Name*

Youth Phone Number (if applicable)

Format: (000) 000-0000.

What level of monitoring are you on?*

Level 1 Monitoring: As a Condition of Level 1 Monitoring, I understand that I do not necessarily have to plan out each time I leave my residence. However, I understand that I must be with a parent/guardian or approved adult anytime I leave my residence unless it is for (1) schooling; (2) some medical/therapy appointments with verification; or (3) court ordered programming. Use this schedule to report known recurring times that you are out of your home (i.e. set school times, programming times, or therapy appointments)*

I understand and will enter any recurring appointments below.I understand and do not have any recurring appointments to report.

Level 2 Monitoring: As a Condition of Level 2 Monitoring, I understand that I do not necessarily have to plan out each time I leave my residence. However, I understand that I must be with a parent/guardian or approved adult anytime I leave my residence unless it is for (1) schooling; (2) some medical/therapy appointments with verification; or (3) court ordered programming. Use this schedule to report known recurring times that you are out of your home (i.e. set school times, programming times, or therapy appointments)*

I understand and will enter any recurring appointments below.I understand and do not have any recurring appointments to report.

Level 3 Monitoring: As a Condition of Level 3 Monitoring, I understand that I do not necessarily have to plan out each time I leave my residence. However, I understand that I must be with a parent/guardian or approved adult anytime I leave my residence unless it is for (1) schooling; (2) some medical/therapy appointments with verification; or (3) court ordered programming. Use this schedule to report known recurring times that you are out of your home (i.e. set school times, programming times, or therapy appointments)*

I understand and will enter any recurring appointments below.I understand and do not have any recurring appointments to report.

Level 4 Monitoring: You receive up to three hours of incentive time (including travel time) that you can utilize in 30 minute increments. Use of this incentive time must be scheduled now. Failure to do so will result in the loss of incentive time as scheduled edits, additions, and revisions are not permitted. For additional information regarding the use of your incentive time - please review your conditions.*

I understand and will scheduled my incentive time now.I understand and will not be scheduling my incentive time this week.

Level 5 Monitoring: You receive up to one hour of incentive time (including travel time) that you can utilize in 30 minute increments. Use of this incentive time must be scheduled now. Failure to do so will result in the loss of incentive time as scheduled edits, additions, and revisions are not permitted. For additional information regarding the use of your incentive time - please review your conditions.*

I understand and will scheduled my incentive time now.I understand and will not be scheduling my incentive time this week.

I understand.I understand and have received approval from the court (requires verification) and will enter the request below.

I understand.

Parent/Guardian Name*

Parent/Guardian Phone Number*

Format: (000) 000-0000.

Enter your email address below to receive a copy of the completed and submitted schedule.*

example@example.com

YesNo

MONDAY DATE

Date

Enter your schedule for Monday below. Click each box to enter the information.

Rows	Purpose of Leaving	Location (Address)	Start Time	End Time	Travel Time (one-way)
1
2
3
4
5

YesNo

TUESDAY DATE

Date

Enter your schedule for Tuesday below. Click each box to enter the information.

Rows	Purpose of Leaving	Location (Address)	Start Time	End Time	Travel Time (one-way)
1
2
3
4
5

YesNo

WEDNESDAY DATE

Date

Enter your schedule for Wednesday below. Click each box to enter the information.

Rows	Purpose of Leaving	Location (Address)	Start Time	End Time	Travel Time (one-way)
1
2
3
4
5

YesNo

THURSDAY DATE

Date

Enter your schedule for Thursday below. Click each box to enter the information.

Rows	Purpose of Leaving	Location (Address)	Start Time	End Time	Travel Time (one-way)
1
2
3
4
5

YesNo

FRIDAY DATE

Date

Enter your schedule for Friday below. Click each box to enter the information.

Rows	Purpose of Leaving	Location (Address)	Start Time	End Time	Travel Time (one-way)
1
2
3
4
5

YesNo

SATURDAY DATE

Date

Enter your schedule for Saturday below. Click each box to enter the information.

Rows	Purpose of Leaving	Location (Address)	Start Time	End Time	Travel Time (one-way)
1
2
3
4
5

YesNo

SUNDAY DATE

Date

Enter your schedule for Sunday below. Click each box to enter the information.

Rows	Purpose of Leaving	Location (Address)	Start Time	End Time	Travel Time (one-way)
1
2
3
4
5

Yes, I have entered all of the required information and will not be making any edits once submitted.No, I need to enter more information.

By signing this document, I swear or affirm the information recorded is true and accurate to the best of my knowledge. I understand that unless it is documented on this schedule, I am not permitted to leave my residence. I understand that only in an emergent situation may the schedule be revised.

**A staff member will contact you to let you know that your schedule has been approved**

On-Call Officer: 317-670-5094

Youth Signature*

Date*

Date

Parent Signature*

Date*

Date

Please verify that you are human*

Johnson County Juvenile Community Corrections Monitored Supervision Weekly Schedule - Youth

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday