Fillable Interstate Compact for Juveniles - Out of State Travel Permit and Agreement to Return

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Interstate Compact for Juveniles - Out of State Travel Permit and Agreement to Return

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U.S.A. forms for Commonwealth of Massachusetts

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INTERSTATE COMPACT FOR JUVENILES
OUT OF STATE TRAVEL PERMIT AND AGREEMENT TO RETURN
FORM VII
VACATION/VISIT ONLY VISIT FOR TESTING RESIDENCE PLACEMENT IN RESIDENTIAL FACILITY
To:
From:
(Receiving State)
(Sending State)
From:
(Agency/Department)
(Phone #)
Re:
(Juvenile’s Name)
(DOB)
(Race/Sex)
*If known: *Ht.
*Wt.
*Eye Color:
*Hair Color:
(Offense)
(Court/Agency #)
(Legal Status)
Current Residence
Name:
Relationship:
Address:
Phone:
Permission is granted to the above-named juvenile to visit the State of
from
until
(Date)
(Date)
During which time the juvenile
will be staying with/at:
(Name/Facility)
(Relationship)
at
(Full Address)
(City)
(State)
(Zip)
(Phone #)
Reason for Visit:
Special
Instructions/Other
Comments:
Juvenile’s Statement of Understanding
I, recognize I am under the legal custody/jurisdiction or supervision of the State of
. I hereby agree to comply with the rules and regulations of the Interstate Compact
for Juveniles and the laws of the sending and receiving state including the above conditions and instructions. I
understand my failure to comply with these conditions may result in a warrant or requisition being issued for my
arrest or return.
I have read, or have had read and explained to me, the Statement of Understanding.
(Juvenile’s Signature)
(Date)
Witnessed by:
(Signature of Caseworker or Probation/Parole Officer)
(Title)
(Date)
Approved by:
(Signature of Supervisor)
(Title)
(Date)
ICJ Travel Permit | Rev. 11-14-16
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Interstate Compact for Juveniles - Out of State Travel Permit and Agreement to Return

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Completed 13 May 2020

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