25 MRT Juvenile Information Sheet

Johnson County Juvenile Community Corrections

Program Participant Information Sheet
Date Completed

MonthDayYear
Date
Program Name
Youth Name
Youth Date of Birth

MonthDayYear
Date
Gender
Address

Youth Address

Street Address Line 2

CityState

Zip
Does the youth currently have their own cell phone?

YesNo
Does the youth currently have possession of this phone?

YesNo
Cell Phone Number
Format: (000) 000-0000.
Height
Weight
Hair Color
Eye Color
Resides With
Parent/Guardian Information

to be completed by the parent/guardian the youth resides with.
Parent Guardian Name
Relationship to Youth
Phone Number
Format: (000) 000-0000.
Phone Number 2
Format: (000) 000-0000.
Place of Employment
Work Phone
Format: (000) 000-0000.
Emergency Contact Name
Contact Phone
Format: (000) 000-0000.
Youth Education Information
School Status

CompletedGood StandingSuspendedExpelledWithdrawnNot Enrolled
School Name
Last Completed Education Level
Youth Driver's License Information
Status of License

Non-IssuedIssued; Good StandingIssued; SuspendedPermit Issued
Drivers License Number
Expiration Date

MonthDayYear
Date
Youth Employment Information
Employment Status

Not employedEmployedSeeking EmploymentNot Seeking Employment
Place of Employment
Employer Phone Number
Format: (000) 000-0000.
Date of Hire

MonthDayYear
Date
Rate of Pay
Average Hours per Week
Supervisor Name
Phone Number
Format: (000) 000-0000.
Typical Days and Times Worked
Youth Medical Information
Does the youth currently have medical insurance coverage?

YesNo
Company Name
Group Number
Policy Number
Is the youth currently under the care of a licensed physician for a medical ailment?

YesNo
Are there any medical concerns with the youth participating in programming?

YesNo
If yes to above question please indicate your concerns
Is the youth currently taking any prescription medications?

YesNo
If yes please list those medications here
Is the youth currently pregnant or have reason to believe they are pregnant?

YesNo
Does the youth have any physical restrictions and/or limitations that programming staff should be aware of?

YesNo
If yes please list those restrictions here
If you believe the youth is pregnant or have a medical concern that prevents the youth from participating in programming, you must submit a note from your licensed physician indicating such.
Parent/Guardian Medical Information

to be completed by the parent/guardian participating in programming.
Do you currently have medical insurance coverage?

YesNo
Company Name
Group Number
Policy Number
Are you currently under the care of a licensed physician for a medial ailment?

YesNo
Do you have any medical concerns related to your ability to participate in programming?

YesNo
If yes to above question please indicate your concerns
Are you currently taking any prescription medications?

YesNo
If yes please list those medications here
Are you currently pregnant or have reason to believe you are pregnant?

YesNo
Do you have any physical restrictions and/or limitations that programming staff should be aware of?

YesNo
If yes please list those restrictions here
If you believe you are pregnant or have a medical concern that prevents you from participating in programming, you must submit a note from your licenses physician indicating such.
Signature
Youth Printed Name
Youth Signature
Date

MonthDayYear
Date
ParentGuardian Printed Name
ParentGuardian Signature
Date

MonthDayYear
Date
Please verify that you are human*
Should be Empty:

Johnson County Juvenile Community Corrections

Parent/Guardian Information

Youth Education Information

Youth Driver's License Information

Youth Employment Information

Youth Medical Information

Parent/Guardian Medical Information

Signature