Transforming the Fabric of Family and Community Through Reformative Collaboration, Education, and Advocacy

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Referral Source / Fuente de referencia*

Courts / Tribunales

School / Escuela

Community / Comunidad

Parent /Madre o Padre

Police / Policia

Municipality / Municipio*

Arlington

Danville

Falls Church

Date of Incident/Fecha del Incidente*

MM slash DD slash YYYY

Police Report # / reporte policial*

Name/Nombre*

First Last

Address/Dirección*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

PhoneTelephone/ Teléfono*

Email/ Correo Electrónico*

Name of person submitting this form/Nombre de la persona que envía este formulario*

First Last

Are you the victim?/¿Eres la víctima?*

Yes

Consent*

Thank you for your interest in Promoting Empathy through Equitable Resolution (PEER) and Youth Peer Court, collaborative, community-based restorative justice programs. By providing information, you authorize CYFA (Center for Youth and Family Advocacy) to contact you regarding PEER and YPC.

Participation in PEER and YPC is based on a case-by-case analysis. The completion and submission of this form does not obligate you or your child to participate in PEER or YPC. Additionally, the completion of this form does not create a relationship with CYFA or its programs.

CYFA agrees that the contact information contained in this form will not be shared outside of CYFA.

I agree

2111 Wilson Boulevard, 8th Floor

Arlington, VA 22201

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CYFA is a 501(c)(3), tax-exempt nonprofit organization that works to disrupt systemic racism and eliminate structural barriers so that all young people, families, and the community have equitable access to the opportunities and resources necessary to thrive.

CYFA is committed to transforming systems through restorative practices, education, and advocacy in order to empower young people to create and achieve successful outcomes for self, family, and community.

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