Declaration Of Proposed Guardian {PRB-PGN-001}

PGF-1 (Revised 2/19) -CONFIDENTIAL- 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 - CONFIDENTIAL - SUPERIOR COURT OF CALIFORNIA COUNTY OF SAN FRANCISCO P roposed Guardianship of (name of the child (ren) ): Case No.: Confidentia l Declaration of Proposed Guardian Please complete the following questions for each person applying for guardianship. (1) (ren)? (2) Do the parents agree that you can be the guardian? Yes No Not sure If No, or Not sure, please explain: (3) Your full legal name: Your email address: Your date of birth: / / (4) Your education (last grade completed): American LegalNet, Inc. www.FormsWorkFlow.com PGF-1 (Revised 02/2019) CONFIDENTIAL- 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Your current job title: Name, address, and telephone number of current employer: (5) Are you in good health: Yes No If No, please explain: (6) Are you currently or were you previously appointed as the guardian of any other child(ren)? Yes No If Yes, please state the County where you were appointed as a guardian, the date you were appointed, and the name(s) of the child(ren) who was/were legally placed in your care: (7) Tell us about everyone who lives with the child(ren), or has frequent contact with the child(ren). If you need more room, please list additional names and information on a separate sheet of paper and attach after the last page of this form: Complete Legal Name Date of Birth Relat ionship to Child(ren) Social Security No. License / ID No. (8) Who has/have the child(ren) lived with since birth? List addresses, American LegalNet, Inc. www.FormsWorkFlow.com PGF-1 (Revised 02/2019) CONFIDENTIAL- 3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 relationships, and dates of residence: (9) Does/do the child(ren) have any special emotional, psychological, educational or physical needs? Yes No If Yes, please explain what the needs are and what you would do to meet the needs: (10) Will the child(ren) need day care? Yes No If Yes, give information about the child(ren) Name of day care provider: Day care address: Day care Telephone number: (11) Is/are the child(ren) in school? Yes No If Yes, please provide information about the child(ren)(s): Name of S choo l: School A ddress: School Telephone N umber: Name of S chool: School A ddress: School Telephone N umber: If Yes, please attach recent report card(s)/proof of enrollment in school. (12) Will the child(ren) have their own room in your house? Yes No If No, please state who shares a room with the child(ren): (13) Is there a firearm in the home? Yes No American LegalNet, Inc. www.FormsWorkFlow.com PGF-1 (Revised 02/2019) CONFIDENTIAL- 4 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 If Yes, how is it stored? (14) Will you get or ask for financial support to help take care of the child(ren)? Yes No If Yes, please explain type and amount of financial support: (15) Do you or does anyone in your home have an arrest record? Yes No If Yes, please explain what the charges were, the date and place of offense(s), and how the case(s) ended, such apiece of paper to this form, if more space is needed. (16) Is/are the child(ren) involved in any other Court case? This can be in Juvenile Court, Family Court or any other Court. Yes No If Yes, please state which Court, the case number, and why: (17) Have you, or anyone who lives with you, had any contact with Child Protective Services of the Department of Human Services? Yes No If Yes, please explain: (18) Where does/do the child(ren) get health and dental care? Name and telephone number of the child(ren)medical clinic: Approximate date of most recent medical appointment: American LegalNet, Inc. www.FormsWorkFlow.com PGF-1 (Revised 02/2019) CONFIDENTIAL- 5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 Name and telephone number of the child(r Approximate date of most recent dental appointment: Please attach a copy of the minor(s) health insurance card and immunization record as proof of routine and consistent medical care. (19) Does speak and understand English? Yes No If No, please identify the other language(s): (20) Please attach a copy of the child(ren) If the birth certificate is in another language, please provide an English-language translation of the birth certificate. (21) Please provide the name and telephone number of someone who will always know how to contact you. In-person interviews are required. Please be advised a Court Investigator will be contacting you to schedule a meeting in your home with you and the child(ren). required. I declare under penalty of perjury under the laws of the State of California that the above information is true and correct. In signing below, I consent to a complete referral history background screening by the San Dated: Signed: Your name (Type or print) American LegalNet, Inc. www.FormsWorkFlow.com