Colorado Court of Appeals 2 East Fourteenth Avenue, Suite 300 Denver, Colorado 80203-2115 ________ District Court, Judge ___________, Case # ____________ IN THE MATTER OF THE PETITION OF: ___________________________________ [Name of Minor] For a Waiver of Parental Notification Requirements Concerning V COURT USE ONLY V an Abortion Attorney, if Minor Represented (Name and Address): Case Number: Phone Number: E-mail: FAX Number: Atty. Reg. #: Division Courtroom NOTICE OF APPEAL The Petitioner, a minor, states: 1. The district court has denied my petition to have an abortion without telling my parent(s), guardian or foster parent.2. I ask that I be given permission by this court to have the abortion without telling my parent(s), guardian or foster parent on the grounds stated in the Petition filed with the district court on _________________________, 20__.3. I believe the district court was wrong in its decision because:___________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________.4. A copy of the district courts decision is attached to this Notice of Appeal. 5. I ask the court to appoint a lawyer to represent me at no cost to me. I have a lawyer and ask the court to appoint that person to continue to represent me. My lawyers name, business address, telephone and fax numbers are: _____________________________ ___________________________________________________________________________________ I do not want to be represented by a lawyer. 6. I understand that the court proceedings and my court file are confidential and cannot be disclosed to anyone, including my parent(s), guardian or foster parent. 7. I request that the court contact me about its decision in the following way (check one): Via Fax: #____________________________________; Attn:_______________________________ Via Telephone: #___________________________________; Attn:_____________________________ Via E-mail: ______________________________________________ Via Beeper or Pager #______________________________________ Via First Class Mail: _________________________________________________________________ _________________________________________________________________________________JDF 15 09/03 NOTICE OF APPEAL >>>> 2 Via My Attorney 8. I request that the Court provide me with a certified copy of the courts order in the following way (check one): Via First Class Mail: _________________________________________________________________ _________________________________________________________________________________ Via My Attorney Via the Court File for pickup by me or _________________________ who has my permission to pick up the certified copy from the court file at the courthouse9. The name, business address, and telephone number of the clinic or doctor who would perform the abortion are (this information is not necessary but optional if you want to have the courts decision sent directly to the clinic or doctor): ________________________________________________________________________ ______________________________________________________________________________________.WHEREFORE, I request that this court reverse the dist rict court and allow me to have the abortion withouttelling my parents. Respectfully submitted this ____ day of ___________, 20__. _________________________________________________ Signature of the Minor _________________________________________________ Signature of Attorney, if minor is represented JDF 15 09/03 NOTICE OF APPEAL