DISTRICT TEEN COURTS (Sample Form)

National Headquarters: P. O. Box 17513, San Antonio, Texas 78217-0513 Tel. (210) 432-8416 www.angelfire.com/biz/nationalteencourts ntca@earthalliance.com

TCA² = The formula for helping young adults become mature, responsible adults

Through education, law-related education, job-related education, counseling, direction and leadership programs

Teen Courts approved in Texas under Chapter 45, Texas Code of Criminal Procedure, Article 45.55 and the Texas Family Code

For the purpose of dismissing Teenagers' Traffic citations and Class C Misdemeanors

National Executive Director National Assistant Exec. Director

Sir Richard D. Weaver Earl H. Guptill

Hidalgo De San Antonio De Bexar

ASSISTANCE INFORMATION BY PARENTS

OF TEENAGE PARTICIPANT OF TCA² TEEN COURT PROGRAM

(This questionnaire is beneficial to us for the purpose of helping your teenager and is kept confidential.)

Teenager's Name _______________________________________________ Date: ____________

Father's Name ______________________________ Mother's Name ___________________________

Legal Guardian's Name (if appropriate) _________________________________________________

Father's Address _____________________________________________ Phone ______________

Mother's Address (if different) ________________________________________ Phone ___________

Father's Occupation _______________________________ Mother's ____________________________

How did you hear about the National Teen Courts of America And Teen Clubs of America, Inc. (TCA²) District Teen Court Program?

_______________________________________________________________________________

What do you think about the District Teen Court Program ?____________________________________ _____________________________________________________________________________________

Did you know that teenagers completing the District Teen Court Program can keep their driving and criminal (misdemeanor) records clean? _________________

Did you know that the District Teen Court Program provides FREE Training Seminars to help teenagers? __________

Does your teenager get along with all members of the family? ___ Yes ___ No, not with _______________ __________________________________________________________

Has your teenager been in trouble before? ___ No ___ Yes, when _________________________________ ___________________________________________________________________________________

What does your family enjoy doing together? __________________________________________________

What did you family enjoy before, but you are not doing now? _____________________________________

______________________________________________________________________________

Do you help your teenager with home work? ___ Yes ___ No, because _______________________________

___________________________________________________________________________________

Does your teenager smoke? ___ Y ___ N Drink Alcohol? ___ Y ___ N

Has your teenager Experimented with Drugs? __ Y ___ N

Does your teenager have a job? ___ N ___Y, with ________________________________________

Do you want your teenager to have a job? ___ Y ___ N

Do you smoke ___ Y ___ N Drink Alcohol? ___ Y ___ N Experimented with Drugs ___ Y ___ N

Do you have a driver's license? ___ Y ___ N Do you own a car? ___ Y ___ N Insured? __Y ___ N

I am providing the following additional information in hopes that it will be of help to the District Teen Court Program in helping my teenager: __________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Parent or Guardian's Signature ___________________________________ Copyright 1989 Revised 1994