INSTRUCTIONS FOR EVALUATION FACILITY: voluntary admission. MC-415 (8/18)(cs) AS 47.30.725(b) NOTICE OF VOLUNTARY ADMISSION IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT In the Matter of the Necessity ) for the Hospitalization of: ) ) ) ) Case No. , ) Respondent. ) Date of Birth: ) NOTICE OF VOLUNTARY ) ADMISSION To: Superior Court at , Alaska. The court ordered that the respondent be hospitalized for evaluation at one of the facilities below. Pursuant to that order, the respondent was delivered to the following facility on : Alaska Psychiatric Institute PeaceHealth Ketchikan Medical Center Bartlett Regional Hospital Yukon-Kuskokwim Delta Reg. Hospital Fairbanks Memorial Hospital The respondent voluntarily admitted to this facility on , at am pm. Date Signature Print Name and Title Phone Number E-mail Address I certify that on , a copy of this notice was provided to: respondent parent/guardian PDA AGO OPA (only if respondent is a minor) By Clerk: American LegalNet, Inc. www.FormsWorkFlow.com