ORDER TO PROVIDE EDUCATIONAL RECORDS AND RECEIPT JD-JM-178 Rev. 7/12 C.G.S. §§ 46b-120; 46b-121 The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA. Telephone number STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov JUVENILE MATTERS Address of Court Docket number Name of child Grade Sex Date of birth Address of child Indian tribe/reservation if any Name of mother Address of mother Name of father Address of father Name of guardian, if any Address of guardian Name of school Address of school Name and title of contact person at school Telephone number Fax number Case type Child Protection Delinquency Family With Service Needs Emancipation Other The child named above currently has a case pending before the Superior Court for Juvenile Matters. For purposes of determining (check all that apply): the need for services placement of the child final disposition of the case Order The following records are ordered to be provided to the Court location listed above by ___________________: (date) school transcript academic performance types of school programs school behavior enrollment status expulsion and suspension attendance reports meetings with parents special education other If records are incomplete or do not exist, please attach an explanation for the Court. Name of Judge Judge's signature Date Records produced in response to the above order shall be: -- used only for dispositional purposes and -- maintained under seal by the Court and -- released only after a hearing or with the consent of the child Receipt/Response To Order Please acknowledge receipt of the court order for educational records by signing below and returning the records to the requesting Superior Court for Juvenile Matters. (Check all that apply:) school transcript academic performance types of school programs school behavior enrollment status currently expelled attendance reports meetings with parents special education other explanation for any incomplete or non-existent records requested I certify that the items checked above are complete and accurate copies. Signed Name of person signing at left Title Date American LegalNet, Inc. www.FormsWorkFlow.com