[directive] Agency: ___________________________________  County: ____________________________  Case No.: ____________________  Date of Incident: __________________________________  Officer: _______________________________________________________________________  Complainant/Victim: ____________________________________________________________  Offense: ______________________________________________________________________  Juvenile: ______________________________________________________________________  Race/Ethnicity*:__________  D.O.B.:______  Age: _____  Gender (M/F/Non-Binary):________ *Select Caucasian, Black, Hispanic, Asian, American Indian, Other, or Unknown  If race/ethnicity is not apparent, ask the juvenile or their parent/guardian/caregiver/designee.  Parent(s)/Guardian/Caregiver/Designee: _____________________________________________  ______________________________________________________  Address: ______________________________________________________  Phone Number: ______________________________________________________  I, ________________________________, agree to have the matter listed above handled  Juvenile through a stationhouse adjustment by the ___________________________________________.  Law Enforcement Agency  In order to successfully complete the stationhouse adjustment, I agree to abide by the following terms and conditions:  1.  ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________  2.  ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ 29  3.  ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________  4.  ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________  5.  ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________  ________________________________________________________________________  ________________________________________________________________________  I understand that if I do not abide by these terms and conditions, formal charges may be filed.  Signatures/Approvals:  *Victim/complainant participation is encouraged, it is not a requirement.  Signatures or telephone authorization permitted, when applicable.  Juvenile: ______________________________________________  Parent/Guardian/Caregiver/Designee*: ______________________________________________ (or telephone authorization)  Victim/Complainant*: ______________________________________________ (or telephone authorization)  Officer/Detective: ______________________________________________  Date: ______________________________________________  Name of Prosecutor/Designee whom approved, if required: ______________________________  30  Appendix B