A Visitor Request Form – Fill Out and Use This PDF

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

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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.