Request for Inclusion on Juvenile Abuse/Neglect/Dependency Court Appointed List(s) Name: _______________________________ Firm Name: _________________________________ Address: _____________________________ Phone: _______________ ____________________________________ Cell Phone: ___________________ ____________________________________ Wake County Mailbox #: ___________ NC State Bar #: _______________________ Email: ______________________________________ Fax: ________________ Please check all that apply: Yes, my cell phone number may be given to other attorneys that are on the Juvenile A/N/D Court’s List(s). Yes, my e-mail address may be given to other attorneys that are on the Juvenile A/N/D Court’s List(s). I request inclusion on the following lists: Attorney for Parent - A/N/D Petition Attorney for Parent - TPR Petition Guardian ad Litem for Parent Conflict Guardian ad Litem-Attorney Advocate THIS SECTION MUST BE COMPLETED FOR INCLUSION ON ANY LIST I certify the following: (Check all that apply) I am licensed to practice law in North Carolina. Year: ___________ I have read N.C.G.C. §§7B-100 through 1113 and am competent with the NC Juvenile Code regarding Abuse/Neglect/Dependency Court. I have completed the “Introduction to Abuse/Neglect Dependency Court.” Date: ________________ I have observed a Child Planning Conference. Date: ________________ Signature of Conference Facilitator: ___________________________________ I have observed a minimum of eight (8) placement reviews and/or permanency planning hearings. Date: _______________ Signature of Presiding Judge: _____________________________________ I have completed the Shadowing Agreement (WAKE-JUV(AND)-1A). Date: ________________ Signature of Supervising Shadowing Attorney: ___________________________________________ I have signed the “ACKNOWLEDGEMENT FOR INCLUSION ON THE JUVENILE ABUSE/NEGLECT/DEPENDENCY COURT APPOINTED LIST.” (JUV A/N/D-2). WAKE-JUV(AND)-1 (REV 01/10) (PAGE 1 of 2) American LegalNet, Inc. www.FormsWorkFlow.com I have completed Training/CLEs/Seminars as outlined in Wake County A/N/D Local Rules 5.2 (L): (Please list title, sponsor, date(s) attended) This the ______ day of ____________________ , 20____ . (Signature of Attorney): _______________________________________________ FOR ATTORNEY FOR PARENT-TPR PETITION I have a minimum of one year of experience representing parents in Abuse/Neglect/Dependency Court. Month/Year began: _____________________ I have observed at least one contested Termination of Parental Rights hearing. Date: _____________ Signature of Presiding Judge: __________________________________ _________________________________________________________________________________ FOR GUARDIAN AD LITEM FOR PARENT I have a minimum of one year of experience representing parents in Abuse/Neglect/Dependency Court. Month/Year began: _______________________ I have served as appointed counsel for a parent who has been appointed a Guardian ad Litem. Name of Parent: _____________________________________ File No.: _______J__________ ____________________________________________________________________________________ FOR GUARDIAN AD LITEM-ATTORNEY ADVOCATE I have completed the Guardian ad Litem-Attorney Advocate training. Date: ___________________ I possess a copy of the North Carolina Guardian ad Litem Attorney Practice Manual. I have observed at least one contested Termination of Parental Rights hearing. Date: _______________ Signature of Presiding Judge: _______________________________________ ____________________________________________________________________________________ This attorney meets all of the requirements for inclusion on the following lists: Attorney for Parent - A/N/D Petition Attorney for Parent - TPR Petition Guardian ad Litem for Parent Conflict Guardian ad Litem-Attorney Advocate ______________________________________________ Chief District Court Judge (or designee) Date: ________________________________________ For use by Committee on Indigent Appointments Only -Request for Inclusion on list for: Attorney for Parent - A/N/D Petition Attorney for Parent - TPR Petition Approved Approved Denied Denied ________________________________________________ Public Defender WAKE-JUV(AND)-1 (REV 01/10) (PAGE 2 of 2) American LegalNet, Inc. www.FormsWorkFlow.com