Juvenile ID: ______ DAVIDSON COUNTY JUVENILE COURT

Juvenile ID: ______DAVIDSON COUNTY JUVENILE COURT Home Phone:______

Date:______GENERAL DATA FORMOther Phone:______

Initials:______CHILD’S PERSONAL RECORDAdult File : ______Yes ______No

(please print all blanks in family history)

Legal Name:______Social Security Number:______

CLast,FirstMiddleC

HOCA ______DOB: ______POB: ______Sex: ______Marital: ______H

IRace: ______Ethnicity: ______Eye Color: ______Hair Color: ______I

LHeight: ______Ft. _____In. Weight: ______lbs. Medical Condition: ______L

DDrivers License #: ______Issue Date: ______IssueState:______D

Living Arrangement of child:

I[ ]With both biological parents[ ]With adoptive parents[ ]In an institution: ______I

N[ ] With father and stepmother[ ]With relative[ ]In a group home: ______N

F[ ]With mother and stepfather[ ]Independent[ ]With foster family: ______F

O[ ]With mother[ ]Unknown[ ]In a residential center: ______O

[ ]With father[ ]Other: ______

Special Ed. Class: ______School: ______Last Grade Completed: ______

Current Address: ______City: ______State: ______Zip: ______

Home Phone: ______Other Phone: ______

______

FAMILY HISTORY

MOTHER:

Name: ______Social Security Number: ______

Last, First Middle

Address: ______Apt#:______City/State: ______Zip:______

Married: Yes No Race: ______Birthdate: ______E-Mail Address: ______

Home Phone: ______Employer: ______

Work Phone: ______Work Address: ______

FATHER:Legitimated: ______

Name: ______Social Security Number: ______

Last, First Middle

Address: ______Apt#:______City/State: ______Zip:______

Married: Yes No Race: ______Birthdate: ______E-Mail Address: ______

Home Phone: ______Employer: ______

Work Phone: ______Work Address: ______

LEGAL GUARDIAN:Relationship: ______

Name: ______Social Security Number: ______

Last, First Middle

Address: ______Apt#:______City/State: ______Zip:______

Sex: ______Race: ______Birthdate: ______E-Mail Address: ______

Home Phone: ______Employer: ______

Work Phone: ______Work Address: ______

STEP-PARENT:

Name: ______Social Security Number: ______

Last, First Middle

Address: ______Apt#:______City/State: ______Zip:______

Sex: ______Race: ______Birthdate: ______E-Mail Address: ______

Home Phone: ______Employer: ______

Work Phone: ______Work Address: ______

File #: ______DAVIDSON COUNTY JUVENILE COURTPage 2

Last Name:______GENERAL DATA FORM

CHILD’S PERSONAL RECORD

(please print)

PETITIONER: ______SSN#: ______DOB: ______

Last, First Middle

RELATIONSHIP TO CHILD(REN): ______

MAILING ADDRESS: ______

CITY/ST: ______ZIP: ______HM PHONE: ______WK PHONE: ______

E-Mail Address: ______EMPLOYER: ______

ATTORNEY: ______FOR: ______

Last, First Middle

FIRM: ______

MAILING ADDRESS: ______

CITY/ST: ______ZIP: ______PHONE: ______FAX: ______

E-Mail Address: ______

ATTORNEY: ______FOR: ______

Last, First Middle

FIRM: ______

MAILING ADDRESS: ______

CITY/ST: ______ZIP: ______PHONE: ______FAX: ______

E-Mail Address: ______

ATTORNEY: ______FOR: ______

Last, First Middle

FIRM: ______

MAILING ADDRESS: ______

CITY/ST: ______ZIP: ______PHONE: ______FAX: ______

E-Mail Address: ______

ATTORNEY: ______FOR: ______

Last, First Middle

FIRM: ______

MAILING ADDRESS: ______

CITY/ST: ______ZIP: ______PHONE: ______FAX: ______

E-Mail Address: ______

SIBLING:

Name: ______Date of Birth: ______File #: ______

Rev. 10/1/13