A Visitor Request Form – Fill Out and Use This PDF

The A Visitor Request Form is issued by West Virginia's Division of Juvenile Services. It lets approved adults apply to visit juvenile offenders in state facilities. Fill out your personal details, list your relationship to the offender, and disclose any criminal history. All applications require a background check before visits are approved. Click below to download and complete the form for free.

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A Visitor Request Form PDF Details

The West Virginia Division of Juvenile Services uses this visitor request form to screen adults who want to visit youth in state-run juvenile facilities. Every applicant must pass a background check before visits are approved.

To complete the form, you must provide your full name, current address, date of birth, and a valid photo ID. You also need to state your relationship to the juvenile offender and list any other offenders at the facility you intend to visit.

The form requires a full criminal history disclosure. You must report any arrests, indictments, felony convictions, and whether you are currently on probation or parole. Providing false information will result in denial of your application.

Visitors under 18 and those bringing minors to the facility must follow additional rules set by the facility. Contact the Division of Juvenile Services before submitting if this applies to your situation. By signing the form, you authorize a background check and confirm that all information is accurate.

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

Form Preview Example

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.

			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) 558-2965 or (304) 558-6032

Resident Visitation

Policy #510

April 1, 2012

Attachment #1

Page 2 of 2

How to Edit A Visitor Request Form Online for Free

Steps to Fill Out the Visitor Request Form

Follow these steps to complete the West Virginia DJS visitor request form correctly and avoid delays in the approval process.

Download the PDF. Click the button at the top of this page to open the form in your browser or save it to your device. Our free PDF editor lets you fill out the form without any software downloads.
Fill in your personal details. Enter your full legal name, current home address, date of birth, phone number, and ID information in the fields provided.
Identify the juvenile you wish to visit. Write the juvenile's full name and facility ID. State your relationship clearly, such as parent, sibling, or family friend.
Disclose your criminal history. Answer all questions about prior arrests, convictions, and current supervision status. If you are on probation or parole, include your supervising officer's contact details.
Review the visitor rules. If you are under 18 or plan to bring children to the facility, additional approval steps apply. Contact the facility in advance to confirm your eligibility.
Sign and submit. Your signature confirms that all information is truthful. Submit the completed form to the appropriate Division of Juvenile Services facility or office.

Related Visitation Forms by State

Looking for a similar visitor request form from another state or facility? These related forms cover other correctional systems: