Annual Renewal Application-Eligibility Declaration For Inclusion On Approved List {FM-1178}

SUPERIOR COURT OF CALIFORNIA COUNTY OF SANTA CLARA Family Court Services Annual Renewal Application/Eligibility for Inclusion on Approved List of Professional Supervised Visitation Providers Note: This form must be completed for all providers, including each visitation monitor employed by an agency. Full Name Agency, if applicable Title Phone Number Address Address Email Address California Standards of Judicial Administration (Uniform Standards of Practice for Providers of Supervised Visitation) Standard 5.20 and California Family Code Section 3200.5 sets forth and defines the standards of practice, including duties and obligations for professional providers of supervised visitation. Please initial confirming the following: 1. I meet the qualifications set forth in California Family Code Section 3200.5 and California Standards of Judicial Administration 5.20. 2. a. b. I am at least 21 years of age I have no record of a conviction for driving under the influence (DUI) within the last five years. I have not been on probation or parole for the last 10 years. I have no record of a conviction for child molestation, child abuse, domestic violence, or other crimes against a person. I have proof of automobile insurance or I do not transport children as part of my service as a supervised visitation monitor. I have no civil, criminal, or juvenile restraining orders within the last 10 years. I have no current or past order in which I am the person being supervised. c. d. e. f. g. Page 1 of 3 FM-1178 REV 9/12/16 SUPERVISED VISITATION PROFESSIONAL PROVIDER ANNUAL RENEWAL APPLICATION/ELIGIBILITY FOR INCLUSION ON APPROVED LIST American LegalNet, Inc. www.FormsWorkFlow.com h. I am able to speak the language of the minor(s) and parent I am supervising or will provide a neutral interpreter over 18 years of age who is able to do so. I agree to adhere strictly to and enforce the Court order regarding supervised visitation. i. 3. I have met the requirements for 24 hours of training as specified in California Family Code Section 3200.5 and California Standards of Judicial Administration 5.20. 4. I have completed eight (8) hours of training within the last year in the areas specified below, with at least two hours dedicated to Issues Relating to Substance Abuse, Child Abuse, Sexual Abuse & Domestic Violence (item j below). (Provide details in (a) through (k) below) a. b. c. d. e. f. g. h. i. j. k. The Role of a Professional Provider: Hours completed _____ Child Abuse Reporting Laws: Hours completed _____ Recordkeeping Procedures: Hours completed _____ Screening, Monitoring, and Termination of Visitation: Hours completed _____ Developmental Needs of Children: Hours completed _____ Legal Responsibilities and Obligations of a Provider: Hours completed _____ Cultural Sensitivity: Hours completed _____ Conflicts of Interest: Hours completed _____ Confidentiality: Hours completed _____ Issues Relating to Substance Abuse, Child Abuse, Sexual Abuse & Domestic Violence: Hours completed _____ Basic Knowledge of Family & Juvenile Law: Hours completed _____ 5. I agree to meet all safety and security procedures, have the ratio of children to provider as described in the Standards of Judicial Administration 5.20(h) and/or specific Court order, have no conflict of interest, maintain and disclose records as described in the Standards of Judicial Administration 5.20(j), abide by confidentiality standards as described in the Standards of Judicial Administration 5.20(k), and, additionally, meet all the Standards as set forth in Standards of Judicial Administration 5.20. 6. I agree to have reviewed and comply with the six (6) Guiding Principles of the United States Department of Justice, Office on Violence Against Women ("OVW") Safe Havens: Supervised Visitation and Safe Exchange Grant Program, as listed in detail below: i. Principle I, Equal Regard for the Safety of Child(ren) and Adult Victims: Visitation centers should consider as their highest priority the safety of child(ren) and adult victims and should treat both with equal regard. Principle II, Valuing Multiculturalism and Diversity: Visitation centers should be responsive to the background, circumstances, and cultures of their community and the families they serve. Principle III, Incorporating an Understanding of Domestic Violence into Center Services: Visitation centers should demonstrate a comprehensive understanding of the nature, dynamics, and impact of domestic violence and incorporate that understanding into their services. Principle IV, Respectful and Fair Interaction: Visitation centers should treat every individual using their services with respect and fairness, while taking into account the abuse that has occurred within the family. Principle V, Community Collaboration: Visitation centers should seek to operate within a community collaborative which has as its goal to centralize safety of child(ren) and adult victims and hold batterers accountable. The community collaborative will strive (1) to ensure a holistic response to each family member's Page 2 of 3 FM-1178 REV 9/12/16 ii. iii. iv. v. SUPERVISED VISITATION PROFESSIONAL PROVIDER ANNUAL RENEWAL APPLICATION/ELIGIBILITY FOR INCLUSION ON APPROVED LIST American LegalNet, Inc. www.FormsWorkFlow.com vi. needs; (2) to stop continued abuse of child(ren) and adult victims; and (3) to eliminate the social conditions that cause intimate partner violence. Principle VI, Advocacy for Child(ren) and Adult Victims: Visitation centers should work with the community collaborative to ensure that child(ren) and adult victims have meaningful access to services and should actively link individuals to those services. 7. I understand that this document may be made available upon request to any member of the public. I hereby declare under penalty of perjury under the laws of the State of California that by my initials set forth above, the information is true and correct. Date Signature Please send the completed original form to: Director of Family Court Services Superior Court of California, County of Santa Clara 191 North First Street San José, CA 95113 Page 3 of 3 FM-1178 REV 9/12/16 SUPERVISED VISITATION PROFESSIONAL PROVIDER ANNUAL RENEWAL APPLICATION/ELIGIBILITY FOR INCLUSION ON APPROVED LIST American LegalNet, Inc. www.FormsWorkFlow.com