In The Lead 180 Referral Form for Young Adults (Ages 18-24)

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Please complete all fields - this referral form must be fully completed for youth 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.

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

The youth must be 18-24.
Gender (Ex: Female, Male, Nonbinary, Other)*
Pronouns (Ex: He/Him, She/Her, They/Them, Other)*
Contact Phone Number*
Email*
Home Address*
Street Address City Province Postal Code
ORCA/Police Case Number (If Applicable)
Notes Regarding the Young Adult (If Applicable)Is there any additional information you wish for the team at ITL180 to know about the nominee? Please provide any information that is deemed appropriate to share to assist the nominees success in the program.
Type of Referral*A referral to ITL180 can be done as a direct referral made by Community Corrections personnel pursuant to section 717 of the Criminal Code (Alternative Measures), or through a Community Support Agency.
- Direct Referral from Agency
- Direct Referral from Police Agency
- Alternative Measures (AMP)
- Probation Order
- Peace Bond
- Conditional Sentence Order (CSO)
- Youth Justice Committee
Referring Agency*
- Calgary Community Corrections Referral
- Provincial Community Corrections Referral (Outside Calgary)
Referring Agency Name*Please add the name of the referring agency.
Calgary - Referral Source*Select the name of the Calgary agency that is doing the referral.
Provincial - Corrections Referral Source*Select the non-Calgary agency referral source.
Provincial - Police Agency Referral Source*Select the non-Calgary agency referral source.
Referral Source Name - Person*Enter the name of the contact for the referring agaency.
Referral Source Phone Number
Referral Source Email*
Date ITL 180 Must Be Completed By*
YYYY slash MM slash DD

This date is required when ITL 180 is part of a sanction imposed by a Probation Officer. 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