IN THE CIRCUIT COURT OF JEFFERSON COUNTY, ARKANSAS 6^TH  DIVISION

 Jack Jones Juvenile Justice Center -301 E. 2^nd Ave. Pine Bluff Arkansas, 71611

Honorable Earnest E. Brown Jr                                                                        Rod Shelby            

                                    TEEN COURT CONFIDENTIALITY WAIVER

Juvenile: ____________________________             Offense:_______________________

Case #: JV-_____________________                        Offense Date: __________________

I understand that in order to participate in Teen Court, others must be allowed access to my case in order to administer the proceedings and for compliance with the terms of the grants.

I hereby authorize the following to have access to my file and the proceedings with the understanding the information accessed will be limited to the minimum necessary to serve the purpose:

[   ] Teen Court Members and Volunteers who have signed Confidentiality Agreements with the Judge.

[   ] County, State, and Federal agencies who provided grant money for funding Teen Court, as necessary to ensure compliance with the terms of the grants.

[   ]  Private for-profit and not-for-profit organizations as necessary to ensure compliance with funding terms.

OPTIONAL WAIVERS

[    ]  Print media to be present for the proceedings as long as they do not take pictures of me or print my name.

[    ]  Television media as long as they do not film me or disclose my name.

OR:

[    ] Print and Television Media may both be present to record the proceedings and are free to take my picture and film me and use me in their coverage.

WAIVER OF LAWYER

I have decided to make my decision about concerning waiving confidentiality without consulting a lawyer.

_________________________    __________    ____________________        ______

Juvenile                                         Date                 Parent/Guardian              Date

I have read the above statements, any questions I have were answered, and I agree to the waivers as marked.

_________________________    __________    ____________________        ______

Juvenile                                    Date           Parent/Guardian               Date