Request For Inclusion On Juvenile Abuse Neglect Dependency Court Appointed List(s) {WAKE-JUV-01}

Request for Inclusion on Juvenile Abuse/Neglect/Dependency Court Appointed List(s) Name: _______________________________ Address: ____________________________ ____________________________________ ____________________________________ NC State Bar #: _______________________ Please check all that apply: Yes, my cell phone number may be given to other attorneys that are on the Juvenile A/N/D Court's List(s). Yes, my e-mail address may be given to other attorneys that are on the Juvenile A/N/D Court's List(s). Firm Name: __________________________________ Phone: ________________ Fax: _________________ Cell Phone: ___________________ Wake County Mailbox #: ___________ Email: ______________________________________ I request inclusion on the following lists: Attorney for Parent - A/N/D Petition Attorney for Parent - TPR Petition Guardian ad Litem for Parent Conflict Guardian ad Litem-Attorney Advocate THIS SECTION MUST BE COMPLETED FOR INCLUSION ON ANY LIST I certify the following: (Check all that apply) I am licensed to practice law in North Carolina. Year: ___________ I have read N.C.G.C. §§7B-100 through 1113 and am competent with the NC Juvenile Code regarding Abuse/Neglect/Dependency Court. I have completed the "Introduction to Abuse/Neglect Dependency Court." I have observed a Child Planning Conference. Date: ________________ Signature of Conference Facilitator: ___________________________________ I have observed a full morning session of "review cases." Date: _________________ Signature of Presiding Judge: ___________________________________________________ I have observed at least one contested Adjudication/Disposition hearing. Date: ________________ Signature of Presiding Judge: ______________________________________ I have signed the "ACKNOWLEDGEMENT FOR INCLUSION ON THE JUVENILE ABUSE/NEGLECT/DEPENDENCY COURT APPOINTED LIST." (JUV-2). Date: ______________ FOR ATTORNEY FOR PARENT-TPR PETITION I have a minimum of one year of experience representing parents in Abuse/Neglect/Dependency Court. Month/Year began: ___________________________ . I have observed at least one contested Termination of Parental Rights hearing. Date: _____________ Signature of Presiding Judge: ________________________________________ WAKE-JUV (AND)-1 (REV 02/06) (PAGE 1 of 2) American LegalNet, Inc. www.USCourtForms.com FOR GUARDIAN AD LITEM FOR PARENT I have a minimum of one year of experience representing parents in Abuse/Neglect/Dependency Court. Month/Year began: ___________________________ I have served as appointed counsel for a parent who has been appointed a Guardian ad Litem. Name of Parent: _____________________________________ File No.: _______J________ FOR GUARDIAN AD LITEM-ATTORNEY ADVOCATE I have completed the Guardian ad Litem-Attorney Advocate training. Date: ___________________ I possess a copy of the North Carolina Guardian ad Litem Attorney Practice Manual. I have observed at least one contested Termination of Parental Rights hearing. Date: _____________ Signature of Presiding Judge: I have attended other relevant Training/CLEs/Seminars: (Please list title, sponsor, date(s) attended) This the ______ day of ____________________, 20_____. (Signature of Attorney) _______________________________________________ This attorney meets all of the requirements for inclusion on the following lists: Attorney for Parent - A/N/D Petition Attorney for Parent - TPR Petition Guardian ad Litem for Parent Conflict Guardian ad Litem-Attorney Advocate ______________________________________________ Chief District Court Judge (or designee) Date: ________________________________________ For use by Committee on Indigent Appointments Only -Request for Inclusion on list for: Attorney for Parent - A/N/D Petition Attorney for Parent - TPR Petition Approved Approved Denied Denied ____________________________________________________ Public Defender WAKE-JUV (AND)-1 (REV 02/06) (PAGE 2 of 2) American LegalNet, Inc. www.USCourtForms.com