400-00106 - Juvenile Probation Certificate (4/2020) Page 2 of 4
☐ 8 Do
not have any weapons or other destructive devices on you or accessible to you at your home, including
(but not limited to) firearms, ammunition, explosives, and bows.
☐ 9. When your probation officer reasonably suspects that you have been using drugs or alcohol, your probation
officer may require you to submit to a urine and/or breath test for drugs or alcohol.
☐ 10. You shall successfully complete a treatment program at ______________________________________.
☐ 11. Be drug and alcohol free. Do not buy, possess, or use alcohol, marijuana, illegal drugs, or any regulated drugs
unless they are prescribed to you by a medical provider.
☐ 12. Faithfully attend school or training at _____________________________________________________.
☐ 13. Work faithfully at ____________________________________________________ or seek employment.
☐ 14. Remain within the State of Vermont unless granted permission to leave by your probation officer.
☐ 15. Reside at ___________________________________________________________________________.
☐ 16. You shall submit to a drug or alcohol assessment and follow recommendations for treatment.
☐ 17. Notify your probation officer within 24 hours of any change of address or place of residence.
☐ 18. Report to your juvenile probation officer as directed. Answer all reasonable inquiries by your juvenile
probation officer.
☐ 19. Allow your juvenile probation officer to visit you at reasonable times at home or elsewhere.
☐ 20. Sign appropriate releases of information to allow your probation officer to monitor the compliance with your
probation conditions.
☐ 21 For Youthful Offender Only: Participate in electronic monitoring as directed by your probation officer and
abide by all electronic monitoring, user agreements, controls and conditions as directed.
☐ 22. Other: ______________________________________________________________________________
Special Conditions Related to Sexual Offenses
☐ 23. You shall successfully enroll, participate in, and complete a program/treatment for sex offenders as directed
by your probation officer or designee.
☐ 24. You shall not have any contact with your victim(s) __________________________________________
(Victim’s Initials)
(including letters, phone calls, tapes, visits, videos, electronically or any form of contact through a third party)
unless approved and documented in advance by your probation officer.
☐ 25. You may not purchase, possess, or use pornography or erotica. You may not go to adult book stores, sex
shops, topless bars.
☐ 26. You may not own, possess or use a camera, recorder, cell phone, or other electronic device that has recording
capabilities, without prior permission of your probation officer or designee. If permission is granted you must
enable your probation officer to access these devices to monitor compliance with probation conditions.
☐ 27. You may not access or loiter in places where children congregate; e.g., parks, playgrounds, schools, etc., unless
otherwise approved and documented in advance by your probation officer.