2. Name*
3. Date of Birth*
   Date of Birth
5. Address*
6. City*
8. State
9. Zip Code
11. Phone Number*
12. Email Address*
14. Case Number
15. Court Status*
    -- Select One --Home DetentionHome ConfinementSupervision/Probation
16. Probation Officer *
    -- Select One --Abernathy, BillBurns, MichelleDeal, GrantEmery, MichaelFerretti, MargoGilleran, CherylGuerrero, DannyHarris, AngelicaKohl, EstelaMaher, PatrickRandell, MichaelSalgado, RogerSargent, JeremiahSpasari, Kim Vargas, Alex
20. Request to Travel*

    1. Out-of state
    2. Within state
21. Departure*
    Departure

    Departure
22. Return*
    Return

    Return
24. Travel purpose (include name/ place of destination): *
26. Destination address: *
28. City*
29. State*
30. Zip Code
32. Accompanied by: Name/ Phone number
34. Acknowledgement:
    I understand that I am to continue to follow the rules of my probation and I am to cooperate with Lake County Juvenile Probation while on this trip. I also understand that this travel permit is not valid until an approval signature has been provided.
36. Digital Signature
    By entering my name below, I accept and agree with the above terms of my travel.
38. Signature:*
Leave This Blank:


43. Submit

* indicates a required field