PETITION FOR JUDICIAL CERTIFICATION OF ELIGIBILITY FOR ADMISSION Commonwealth of Virginia Va. Code § 37.2-806 Case No. .................................................................................. [] .............................................................................................................................................................. [ ] In Re: .................................................................................................................................................. NAME OF RESPONDENT General District Court Juvenile &Domestic Relations District Court I, the undersigned Petitioner, state under oath to the best of my knowledge and belief that: 1. I am the Respondent's [ ] mother [ ] father [ ] guardian [ ] other responsible person. 2. The Respondent has intellectual disability, is in need of training or habilitation, is not capable of requesting admission to a training center pursuant to Virginia Code § 37.2-806, and has been approved for admission by the training center to which it is proposed that the Respondent be admitted. 3. A preadmission screening report was obtained from ................................................................................................................... COMMUNITY SERVICES BOARD OR BEHAVIORAL HEALTH AUTHORITY and the report recommends the admission of the Respondent to a training center for the training or habilitation of persons who have intellectual disability. 4. There is no less restrictive alternative to training center admission for the Respondent, consistent with the best interests of the Respondent. 5. It is proposed that the Respondent be admitted to ................................................................................................................. , a NAME OF TRAINING CENTER training center for the training or habilitation of persons who have intellectual disability and said training center has approved the admission of the Respondent. Wherefore, the Petitioner requests that the Respondent be certified as eligible for admission to the above-named training center pursuant to Virginia Code § 37.2-806. ..................................................... DATE _____________________________________________________________ PETITIONER'S SIGNATURE ............................................................................................................................................................................................................................................................................. PRINT NAME ............................................................................................................................................................................................................................................................................. ADDRESS TELEPHONE NUMBER FORM DC-477 MASTER 07/12 American LegalNet, Inc. www.FormsWorkFlow.com