PETITION AND ORDER FOR PARE NTAL PARTI CIPATION Case No. .................................................... Commonwealth of Virginia Va. Code 16.1-241.2, 22.1-279.3 ........................................................................ DATE OF HEARING ........................................................................ ............................................. Juvenile and Domestic Relations District Court ........................................................................ ...... v. ........................................................................ ............ PETITIONER/SCHOOL BOARD RESPONDENT/PARENT/GUARDIAN/LEGAL CUSTODIAN .... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... .. ................................................................................... ADDRESS ADDRESS ........................................................................ ...... ... ...... ...... ...... ...... ...... ...... ...... ...................................... .... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... .. ................................................................................... TELEPHONE NUMBER TELEPHONE NUMBER ........................................................................ ...... ........................................................................ ........... NAME OF STUDENT RESPONDENTS DATE OF BIRTH .... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... .. ................................................................................... ADDRESS RESPONDENTS SOCIAL SECURITY NUMBER .... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... ...... .. STUDENTS DATE OF BIRTH STUDENTS SOCIAL SECURITY NUMBER The school board for ........................................................................ ................... hereby petitions this court to proceed against the parent named above for willful and unreasonable refusal to participate in efforts to improve the students behavior. The school board specifically requests that: [ ] The court order the parent to meet with school officials to discuss the students improvement in behavior, school attendance or educational progress, the school boards standards of student conduct, and the parents responsibility to assist the school in disciplining the student, maintaining order, or ensuring the childs school attendance. [ ] The court impose a civil penalty not to exceed $500.00 for the parents failure to meet with school officials due to the students suspension or expulsion. [ ] The court order the student or parent to participate in such programs or such treatment as the court deems appropriate to improve the students behavior. ........................................................................ ...................................................................................................... SUGGESTED PROGRAM NAME AND ADDRESS [ ] The court order the student or parent to be subject to the conditions and limitations as the court deems appropriate for the supervision, care, and rehabilitation of the student or his parents. ........................................................................ ...................................................................................................... SUGGESTED CONDITIONS AND LIMITATIONS ................................................ ______________________________________________________________ DATE PETITIONERS SIGNATURE Sworn/Affirmed and signed before me on ............................................................... _______________________ _______________________________________ INTAKE OFFICER American LegalNet, Inc.FORM DC-560 (PAGE ONE OF TWO) 07/04 PDF www.USCourtForms.com>>>> 2 ORDER ........................................................................ ............ PETITIONER/SCHOOL BOARD V. ........................................................................ ............ RESPONDENT/PARENT/GUARDIAN/LEGAL CUSTODIAN The court hereby orders: [ ] a civil fine of $ ....................................................... to be paid to ........................................................................ .. [ ] The parent(s) to meet with school official s; [ ] The [ ] student and/o r [ ] parent to participate in the following program or treatm ent: ....................................................................... ....................................................................................................... PROGRAM NAME AND ADDRESS ....................................................................... ....................................................................................................... [ ] The [ ] student and/o r[ ] parent to be subject to the following conditions and limitat ions: ....................................................................... ....................................................................................................... CONDITIONS AND LIMITATIONS ....................................................................... ....................................................................................................... ....................................................................... ....................................................................................................... ................................................ ______________________________________________________________ DATE JUDGE American LegalNet, Inc.FORM DC-560 (PAGE TWO OF TWO) 07/04 PDF www.USCourtForms.com