Fill and Sign the For a Waiver of Parental Notification Requirements Concerning Form

JDF 11 09/03 PETITION FOR WAIVER OF PARENTAL NOTIFICATION Page 1 of 2 REQUIREMENTS OF §12-37.5-104, C.R.S.  District Court  Denver Juvenile Court__________________________________________County, ColoradoCourt Address:IN THE MATTER OF THE PETITION OF: ___________________________________ [Name of Minor]For a Waiver of Parental Notification Requirements Concerning an Abortion COURT USE ONLY Attorney, if Minor Represented (Name and Address): Phone Number: E-mail:FAX Number: Atty. Reg. #:Case Number:Division Courtroom PETITION FOR WAIVER OF PARENTAL NOTIFICATION REQUIREMENTS OF §12-37.5-104, C.R.S. The Petitioner, a minor, states: 1. I am ___ years old.2.I am approximately ____ weeks pregnant and desire to terminate the pregnancy by abortion.3. I want to have the abortion without telling my parent(s), guardian or foster parent.4.I am am not married.5. I do do not financially support myself.6.I live with my: parent(s) guardian foster parent(s) relative: ____________ (state relationship)other: ______________(state relationship)7.I have have not  been informed about the risks and consequences of having the abortion.8. (Check one or both):I believe I am mature enough to decide on my own to have an abortion without telling my parent(s), guardian or foster parent.It would not be in my best interest to tell my parent(s), guardian or foster parent of the abortion.9. The name, business address and telephone number of the clinic or doctor who would perform the abortion are (this information is optional if you want to have the court’s decision sent directly to the clinic or doctor): _______________________________________________________________________________________ ______________________________________________________________________________________.10.  I ask the Court to appoint a lawyer to represent me at no cost to me. JDF 11 09/03 PETITION FOR WAIVER OF PARENTAL NOTIFICATION Page 2 of 2 REQUIREMENTS OF §12-37.5-104, C.R.S.  I have a lawyer and ask the Court to appoint that person to continue to represent me. My lawyer’s name, business address, telephone and fax numbers are: ___________________________________ _________________________________________________________________________________ I do not want to be represented by a lawyer.11. I understand that the court proceedings and my court file are confidential and cannot be disclosed to anyone, including my parent(s), guardian or foster parent. 12. The Court can let me know of any Court proceedings or decisions in the following way: Via Fax: #___________________________; Attn:_______________________________ Via Telephone: #____________________________; Attn:_______________________________ Via E-mail: ____________________________________________________________ Via Beeper or Pager #______________________________________ Via First Class Mail: __________________________________________________________________________________________________________________________________________________ Via My Attorney13. I ask that the Court provide me with a certified copy of the court’s order in the following way (check one): Via First Class Mail: __________________________________________________________________________________________________________________________________________________ Via My Attorney Via the Court File for pickup by me or ___________________________ who has my permission to pick up the certified copy on my behalf from the court file at the courthouse14. The best days and times for me to come to court are:_______________________________________________________________________________________ _______________________________________________________________________________________WHEREFORE, I request to the Court enter an order allowing me to have the abortion without telling my parent(s), guardian or foster parent. Respectfully submitted this ____ day of ___________, 20___. _____________________________________ Signature of Minor _____________________________________ Signature of Attorney, if Petitioner is represented