2850 College Drive, Rice Lake, WI 54868

715-736-0940

VICTIM OFFENDER CONFERENCING PROGRAM

CONSENT TO PARTICIPATE

We agree to participate in the Victim Offender Conferencing (VOC) Program.

We understand that our participation is confidential. Information about the victim and offender, and details of what happened in the meeting, will not be released to outside parties without consent.

However, it will be reported if information revealed during the conference indicates:

n A violation of law, or

n Someone is being harmed, or

n Someone is in danger of being harmed.

If an informal agreement is reached by the victim and offender, the facilitator will write it on an agreement form or separate sheet of paper, and ask all parties to sign and date it. The parties should indicate on the agreement who they would like to have a copy.

The VOC Program will maintain records of level of participation in the program and will advise the referral source accordingly.

Signatures

___________________________________ __________________________________

Victim Date Parent of Victim (if present) Date

___________________________________ __________________________________

Victim Date Parent of Victim (if present) Date

___________________________________ __________________________________

Offender Date Parent of Offender (if present) Date

___________________________________ __________________________________

Offender Date Parent of Offender (if present) Date

___________________________________ __________________________________

Facilitator Date Facilitator Date

Use back of this form or additional sheets if needed.