In The Lead 180 Referral Form (Ages 14-17) - Calgary Youth Justice Society

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Please complete all fields - this referral form must be fully completed for youth aged 14-17 participation and registration. Please Note: You will receive a certificate of completion from In the Lead via email when the youth has successfully completed the program.

Youth's Legal Name*
First Last
Youth's Name For Class (If Different From Above)
Youth's Date of Birth*
MM slash DD slash YYYY

The youth must be 14-17.
Youth's Gender (Ex: Female, Male, Nonbinary, Other)*
Youth's Pronouns (Ex: He/Him, She/Her, They/Them, Other)*
Youth's Phone Number*
Youth's Email*
Parent/Guardian Name*
Parent/Guardian Phone Number*
Parent/Guardian Email*
Home Address*
Street Address City Province Postal Code
Alternate Parent/Guardian Name
Alternate Parent/Guardian Phone Number (If Applicable)
Alternate Parent/Guardian Email (If Applicable)
Notes Regarding Youth (If Applicable)
Type of Referral*A referral to ITL180 can be done as a direct referral made by a law enforcement agency pursuant to section 6 YCJA, or through a YJCA as part of a sanction imposed under section 10 YCJA.
- Direct Referral from Agency
- Youth Justice Committee Referral
Referring Agency*
- Calgary Referral
- Provincial Referral (Outside of Calgary)
Calgary - Referral Source*Select the name of the Calgary agency that is doing the referral.
Provincial - Referral Source*Select the non-Calgary agency referral source.
Referring Agency Name*Please add the name of the referring agency.
Referral Source Person - Name*Enter the name of the contact for the referal source
Referral Source Phone Number
Referral Source Email*
Agency Case/Incident Number
Date ITL 180 Must Be Completed By*
DD slash MM slash YYYY

This date is required when ITL 180 is part of a sanction imposed by a Youth Justice Committee. The date must be prior to the return date to court.
Name
This field is for validation purposes and should be left unchanged.

Acceptable Valid Government Issued Picture Identification

Driver’s Licence
Alberta Photo Identification Card (issued through Registry Agent Offices)
Passport
Permanent Resident Card
Firearms Licence
Nexus Card
Secure Certificate of Indian Status Card (Federally issued)
Aviation Document Booklet

Acceptable Valid Government Issued Identification

Provincial Healthcare Card
Birth Certificate
Marriage Certificate
Immigration Papers
Citizenship Card (issued within the last 5 years)
Citizenship Certificate