Fill and Sign the Ca Caregiver Form

CASE NUMBER CAREGIVER INFORMATION FORM To the foster parent or relative caregiver of the child: You may submit written information to the court or to the child's social worker, or you may attend review hearings. This optional form may assist you in providing written information to the court. Please type or print clearly in ink and submit the form well in advance of the hearing. Be aware that other individuals involved in the case have access to this information. ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– ––––– –––––––––– –– –– ––––– –– ––––– 3. The child has been living in my home for ––––– ––––– –– –– ––––– –– –– ––––– –– –– ––––– –– –– ––––– JV- 290 SUPERIOR COURT OF CALIFORNIA, COUNTY OF FOR COURT USE ONLY STREET ADDRESS MAILING ADDRESS CITY AND ZIP CODE BRANCH NAME 1. Child's name: Child's date of birth: Child's age: 2. Name of caregiver: Address (confidential): Phone no.: Type of caregiver: Foster parent Relativ e Other (specify): yea rs month s. 4. Current Status of Child's Medical/ Dental/ General Physical and Emotional Health There is no new or additional information since the last court hearing. There is new or additional information since the last court hearing (do not include the names of doctors): 5. Current Status of Child's Education There is no new or additional information since the last court hearing. There is new or additional information since the last court hearing (do not include the names of the schools): 6. a. The child i s is not a special education student. b. If the child is a special education student, please also state the date of the last Individual Education Plan (IEP): 7. Current Status of Child's Adjustment to Living Arrangement There is no new or additional information since the last court hearing. There is new or additional information since the last court hearing: Page 1 of 2 Form Approved for Optional Use Judicial Council of California JV-290 [New January 1, 2002] CAREGIVER INFORMATION FORM Welfare and Institutions Code § 366.21 ~b)electronic form ã 2001 WWW.LawCA.com Law Publishers ––––– ––––– ––––– –– –– –– –– –– –– ––––– –– Number of pages attached (specify): ––––– ––––– –––––NAME OF CAREGIVER: CASE NUMBER NAME OF CHILD: 8. Current Status of Child's Social Skills /Peer Relationships There is no new or additional information since the last court hearing. There is new or additional information since the last court hearing: 9. Current Status of Child's Special Interests /Activities There is no new or additional information since the last court hearing. There is new or additional information since the last court hearing: 10. Other Helpful Information There is no new or additional information since the last court hearing. There is new or additional information since the last court hearing: If you need more space to respond to any section above, please check this box and attach additional pages. Dat e: (TYPE OR PRINT NAME) (SIGNATURE OF CAREGIVER) JV-290 [New January 1, 2002] CAREGIVER INFORMATION FORM Page 2 of 2electronic form ã 2001 WWW.LawCA.com Law Publishers