Vaping Referral Form Offernder:First Name *Last Name *Date of BirthGenderMaleFemaleEthnicityWhiteHispanicAfrican AmericanNative AmericanStreet AddressCityZIP / Postal CodePhone *SchoolGradeParent/Guardian:First Name *Last Name *Street AddressCityZIP / Postal CodeEmail *Home Phone *Cell PhoneReason for ReferralAdminFirst Name *Last Name *PhoneCatch My Breath/Restorative JusticeConsent * The participant named above and his/her parent hereby consents to the release of the following juvenile records. This information exchange is necessary to ensure efficient case management and full participation with the Eau Claire Police Department, Eau Claire County DHS, Eau Claire Area School District (ECASD) and Restorative Justice Program. I hereby authorize Eau Claire Police Department, ECASD, and Restorative Justice to exchange/release the following information. This information may include but not be limited to: 1. This Referral Form 2. Incident related records including; reports, statements, or any supplementary information as needed by the City of Eau Claire Police Department and Restorative Justice staff 3. Records indicating level of participation and cooperation with Restorative Justice Program, ECASD staff, and Eau Claire Police Department. I understand this consent may be revoked at any time through written notice to both Eau Claire Police Department and Restorative Justice Staff. By signature, agree not to hold Eau Claire Police Department, Eau Claire School District, Eau Claire County DHS, or Restorative Justice liable for any information released prior to written revocation:ParticipantBy inputting your electronic signature, you are giving your consent.Date *First Name *Last Name *Date *For RJ Staff Use OnlyHTML____ Successfully Completed Date: __________ ____ Unsuccessful Completion Reason: _________________ ____ No Show Date: __________Submit