Staying connected with loved ones during times of incarceration is crucial for the emotional well-being of both parties. The State of West Virginia Division of Juvenile Services facilitates this through the A Visitor Request form, designed for individuals wishing to visit offenders housed in juvenile facilities across the state. This comprehensive form requires detailed information from the visitor, including personal identification details, relationship to the offender, and whether the visitor is related to or intends to visit other offenders. It also inquires about the visitor's criminal background, including any indictments, felony convictions, and whether they are currently on probation or parole. Additionally, specific regulations apply to visitors under 18 or those aiming to bring children to the facility, ensuring the protection and legal compliance for all involved. Moreover, the form acts as a certification, with the visitor affirming all provided information is true and subject to use for a background check—a mandatory step before visitation approval. The A Visitor Request form emphasizes the importance of maintaining transparent and secure communication channels between juvenile offenders and the outside world, underscoring the Division's dedication to rehabilitation and family unity.
| Question | Answer |
|---|---|
| Form Name | A Visitor Request Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | WV, 2012, 15a, Quarrier |
STATE OF WEST VIRGINIA DIVISION OF JUVENILE SERVICES 1200 Quarrier Street, 2nd Floor
Charleston, WV 25301
** If you have completed this
form for the same offender at another juvenile facility, do not complete form again. Please contact the juvenile facility where the offender is located.
The Juvenile Facility Director or Superintendent has the authority to deny your visit even if your background check has been approved. Please contact the facility where the offender is located for background check approval and to schedule visits.
VISITING REQUEST
1. OFFENDER NAME:____________________________________ 1a. FACILITY NAME ______________________ 2. DJS #__________
3. VISITOR’S FULL NAME :_________________________________________________________________ 3a. DATE___________
(First) |
(Middle) |
(Last) |
|
4. MAILING ADDRESS:_____________________________________________________________________________ |
|||
Street |
City |
State |
Zip Code |
5.PHYSICAL ADDRESS IF DIFFERENT FROM ABOVE:_______________________________________________________________
6.TELEPHONE NUMBER: ( )________________________________________________________________________________
7.DATE OF BIRTH: (Month/Day/Year)______________________________________ 7a. Race:________________ 7b. Sex:__________
8.PLACE OF BIRTH______________________________________________ 8a. SOCIAL SECURITY #___________________________
9.MAIDEN NAME (If applicable)_______________________________________________________________________________
10.EYE COLOR:___________________ 10a. HAIR COLOR:_________________ 10b.WEIGHT:_______________ 10c. HEIGHT:_____________
11.RELATIONSHIP TO OFFENDER_____________________________________________________________________________
12. ARE YOU RELATED TO ANY OTHER OFFENDER(S) AT ANY JUVENILE FACILITY? ____YES ____ NO
(IF YES, PLEASE COMPLETE THE FOLLOWING):
12a. OFFENDERS NAME_______________________________________________ 12b. DJS NO:______________________
12c. OFFENDERS NAME_______________________________________________ 12d. DJS NO:______________________
13.ARE YOU VISITING ANY OTHER OFFENDER(S) AT ANY OTHER JUVENILES FACILITY AT THE PRESENT TIME? ____ YES ____ NO
13a. |
OFFENDERS NAME:_______________________________________________ 13b. |
DJS NO:__________________ |
|
13c. OFFENDERS NAME:_______________________________________________ 13d. |
DJS NO:___________________ |
|
|
13e. |
OFFENDERS NAME:_______________________________________________ 13f. DJS NO:___________________ |
Resident Visitation |
|
Policy |
#510 |
April 1, |
2012 |
Attachment #1
Page 2 of 2
14. ARE YOU CURRENTLY UNDER INDICTMENT FOR A CRIME? ______YES _______NO
14 a. IF YES, PLEASE EXPLAIN THE CIRCUMSTANCES.
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________
15.HAVE YOU EVER BEEN CONVICTED OF A FELONY? _______YES ________NO
15a. IF YES, PLEASE STATE DATE OF CONVICTION, CRIME(S) FOR WHICH CONVICTED, SENTENCE, WHAT FACILITY YOU WERE COMMITTED
TO, AND RELEASED FROM: _______________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
16.WERE YOU OR ANY CHILDREN UNDER THE AGE OF 18 A VICTIM OF THIS OFFENDER(S) CRIME? ______YES ______NO
16a. IF YES, PLEASE STATE THE CIRCUMSTANCES:
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
17.ARE YOU NOW ON PROBATION/PAROLE? ____YES _____NO
17a. IF YES, STATE WHY YOU ARE ON PROBATION/PAROLE: WHEN YOU WILL DISCHARGE FROM PROBATION/PAROLE AND THE NAME
AND TELEPHONE NUMBER OF YOUR PROBATION/PAROLE OFFICER:
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
18.CHILDREN UNDER THE AGE OF 18: YOU MAY ONLY APPLY FOR CHILDREN IF YOU ARE ABLE TO PROVIDE PROOF THAT YOU ARE THEIR PARENT OR LEGAL GUARDIAN. THE PARENT/LEGAL GUARDIAN OF THE CHILD MUST BE ON THE OFFENDER(S) APPROVED VISITING LIST BEFORE ANYONE ELSE MAY BRING IN A CHILD. IF ANYONE OTHER THAN THE PARENT/LEGAL GUARDIAN WISHES TO BRING A CHILD INTO THE COMPLEX, THEY MUST HAVE A NOTARIZED PERMISSION SLIP FROM THE PARENT/LEGAL GUARDIAN.
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|
|
RELATIONSHIP |
RELATIONSHIP |
NAME |
BIRTHDAY |
AGE |
TO VISTOR |
TO OFFENDER |
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
19.CERTIFICATION: I HEREBY AFFIRM THAT ALL ANSWERS TO THE ABOVE QUESTIONS ARE TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND ACKNOWLEDGE THAT THEY MAY BE UTILIZED FOR THE PURPOSE OF CONDUCTING A BACKGROIUND CHECK.
SIGNATURE_____________________________________________________ DATE__________________________________
****Please mail completed request to: State of WV Division of Juvenile Services
Attn: Visitor Request
1200 Quarrier Street, 2nd Floor
Charleston, WV 25301 or Fax to (304)
Resident Visitation
Policy #510
April 1, 2012
Attachment #1
Page 2 of 2