Applicant's Contact Info

Full Name

Date of Birth

Address

City

Zip

Phone

Email

Name of School

Grade

What neighborhood are you from?

What languages do you speak fluently?

What race or ethnicity do you identify with?

Gender
Male Female

Parent Contact Info

Parent/Guardian Name

Phone #

Address

City

State

Zip

Short Answers
1. Why do you want to participate in Peer Court?

2. What strengths or qualities do you possess that make you a good candidate?

3. What are some negative issues affecting your community now?

4. If it were up to you, how might you address one or more of these problems?

5. If you've had any volunteer, leadership or job experience in the past, please explain:  

Agreement
By signing below, we agree to the following terms   
      · I promise that all information given in this application is true and correct.
      · I promise keep confidential all personal information I learn at Peer Court.
      · I give Peer Court permission to use my image and/or my child's image in promotional materials such as photographs, videos, etc.
      · I give my consent to have a background check performed by the Juvenile Probation Department, LiveScan or other agency to check for current probation status and any history of offenses against minors.

 (by typing your name here, you agree that you have read and understood the program expectations and responsibilities, and that all information submitted is true and correct)

Signature of Applicant

Date                          

Signature of Parent

Date                          

Please note: once you are enrolled in the program, both you and your parents will need to sign and return a paper copy of your signature.  

Thank you,

Tony Litwak
Peer Court, California Community Dispute Services
149 Natoma Street, 3rd Floor, San Francisco, CA 94105
Contact 415-865-2524, Tony@peercourt.org, fax 415-865-2538

Please submit only once, and be patient as your form loads (it may take a few moments). You will be shown a confirmation once it has been sent.