Form Jv-290 - Caregiver Information Form - California Superior Court

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JV-290
SUPERIOR COURT OF CALIFORNIA, COUNTY OF
FOR COURT USE ONLY
To keep other people from
STREET ADDRESS:
seeing what you entered on
MAILING ADDRESS:
your form, please press the
CITY AND ZIP CODE:
Clear This Form button at
BRANCH NAME:
the end of the form when
finished.
CHILD'S NAME:
HEARING DATE AND TIME:
CASE NUMBER:
CAREGIVER INFORMATION FORM
To the current caregiver, preadoptive parent, community care facility, or foster family agency caring for the child: You may
submit written information to the court and you may attend review and permanency hearings. You may use this optional
form to provide written information to the court. Please type or print clearly in ink and submit the original and eight copies of
the form to the court clerk's office at least five calendar days (or seven calendar days if filing by mail) before the hearing. Be
aware that other individuals involved in the case have access to this information. See form JV-290-INFO for instructions on
how to complete this form and file it with the court.
1. a. Child's name:
c. Child's age:
b. Child's date of birth:
2. Caregiver Information (Answer only if you are a caregiver, skip #3.):
a. Name of caregiver:
b. Type of caregiver:
Foster parent
Relative
Legal guardian
Preadoptive parent
Nonrelative extended family member
Other (specify):
c. The child has been living in my home for (specify):
years
months.
3. Agency or Facility Information (Answer only if you are an Agency or Facility, skip #2.):
a. Name of agency or facility:
b. Address:
c. Telephone number:
d. Type of facility:
Foster family agency
Community care agency
Other (specify):
e. The child has been placed with our agency/facility for (specify):
years
months, and in the
current home for (specify):
years
months.
f. Name of person completing form:
Title:
g. Hours per week the person completing this form spends with the child (specify):
hours/week.
h. The information on this form consists of
(1)
the observations and recommendations of the person filling out this form.
(2)
the observations and recommendations of a group or team made up of the following individuals (specify):
4. Current Status of Child's Medical, Dental, and General Physical and Emotional Health
There is no new or additional information since the last court hearing.
a.
There is new or additional information since the last court hearing, as follows (do not include the names of doctors):
b.
Page 1 of 2
Form Approved for Optional Use
CAREGIVER INFORMATION FORM
Welfare and Institutions Code, §§ 366.21(c), (d); 16010(f)(3);
Judicial Council of California
Cal. Rules of Court, rule 5.534(m)
JV-290 [Rev. October 1, 2007]

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