WHAT TO PLAN FOR WHEN YOU ARE
PREGNANT AT THE CALIFORNIA
INSTITUTION FOR WOMEN
Introduction
Legal Services for Prisoners with Children is based in Oakland, California.
We
advocate for the human rights and empowerment of imprisoned people, their
children, their family members, and people at risk for imprisonment. We focus on
women in prison and their families, and we stress the importance of family unity
during imprisonment and after release. One major way that we advance our goals
is by providing information, trainings, and technical assistance to women in prison
so that they may become stronger, more knowledgeable advocates for themselves
and others.
This manual is designed specifically for pregnant women at the California
Institution for Women in Corona, California. In it, we strive to answer many
pregnant women’s legal and practical questions about deciding to have a baby,
making arrangements for the baby’s care, and taking the first steps to preserve
family unity while in prison. This manual will also be helpful for family
members of these pregnant women and their advocates. The information in this
manual was provided to us by staff at CIW, CDCR’s Sacramento office, the
Riverside CPS office and the Riverside County Regional Medical Center.
This manual is not intended to replace your lawyer. If you have a lawyer, ask him
or her questions, share information, and tell him or her what you want for your
family. The information in this manual is current as of January 2013 (attachments
updated in January 2019). This
manual is a snapshot in time of what we
understand the current policies are. Please let us know if your experience differs
from what we have been told are
official policies.
Abbreviations in this manual
ACP
Alternative Custody Program
CDCR
California Department of Corrections & Rehabilitation
CIW
California Institution for Women
CPMP
Community Prisoner Mother Program
CPS
Child Protective Services
FSC
Family Services Coordinator
NPIF
Newborn Placement Information Form
OB
Obstetrical
RCRMC
Riverside County Regional Medical Center
4400 Market Street
Oakland, CA 94608
Phone: (415) 255-7036
Fax: (415) 552-3150
www.prisonerswithchildren.org
TABLE OF CONTENTS
What medical treatment should I expect when I am brought to prison? .............................. 3
Where will my baby be born? .............................................................................................. 4
Will someone help me make arrangements for my pregnancy and my baby? ..................... 5
What should I think about when I am choosing someone to take care of my baby
while I am in prison? ..................................................................................................... 6
When does Child Protective Services get involved? ............................................................ 8
What if I do not have anybody to choose as my baby's caregiver? ...................................... 8
Can I request that someone be present when I give birth at the hospital? ............................ 8
What will happen when it is time for me to have my baby? ................................................ 9
How will I get to the hospital? ........................................................................................... 10
What does the hospital social worker do? .......................................................................... 10
What forms will I need to fill out at the hospital? .............................................................. 10
Will I be able to spend time with my baby? ....................................................................... 11
What happens if my baby has special medical needs? ....................................................... 12
When will the hospital call CPS about my baby? .............................................................. 12
Is there anything that will automatically cause CPS to take my baby? .............................. 13
If CPS intervenes and takes my baby, what happens next? ............................................... 13
What happens after I return to prison? ............................................................................... 14
How do I make more formal legal arrangements for my baby? ......................................... 15
What should I do to make sure my baby can visit me at CIW? ......................................... 16
Final thoughts ..................................................................................................................... 17
Attachments: Newborn Placement Information Form
CPMP Eligibility Form
ACP Eligibility Requirements
State Application for Birth Certificate
Declaration of Paternity Sample
Temporary Custody Agreement/Power of Attorney Forms
Written Consent for Minor Visitation Authorization Form
Summary of Anti-Shackling Law
2
What medical treatment should I expect when I am brought to prison?
Medical attention when you first arrive at CIW
Urine tests for pregnancy are not given
automatically. However, if you report that
you might be or are pregnant, or you appear
to be pregnant, or if county jail records note
that you are pregnant, you will immediately
be screened by an OB (obstetrical) nurse and
given a urine dipstick test. If there is a
remote chance that you might be pregnant,
let someone know.
If the urine test is positive, you will have an
appointment with an OB nurse the next day.
Within seven days of your arrival, you will
also be seen by an OB doctor.
If you have any medical conditions that
might complicate your pregnancy, it is
important for medical staff to know this as
well. The medical staff will inform the
supervising obstetrician about any medical
conditions that might complicate your
pregnancy.
Your right to have an abortion
Once your pregnancy is confirmed, you may
make the personal decision that this is not the
right time in your life to have a baby. You
have the right to an abortion even while you
are in prison. You may or may not be given
this information by the nurses, doctor, or
Family Services Coordinator (FSC), so you
may need to be pro-active. Ask for the
information you need.
If you decide that an abortion is the best
choice for you, tell your decision to the nurse,
the doctor, and the FSC as soon as possible,
the sooner the better. This is because there are
limits to abortion rights during later stages of
pregnancy, as well as physical and mental
health concerns. Generally, under California
law, a woman has the legal right to choose an
abortion up through the 16
th
to 18
th
week of
pregnancy. Between the 18
th
and 24
th
week of
pregnancy, a medical judgment must be made
whether it is safe for the woman to have an
abortion. After the 24
th
week of pregnancy, an
abortion is only available for a woman whose
pregnancy puts her life in danger.
The FSC and the OB doctor routinely meet
with pregnant women during their first week
at CIW. This is an ideal time to ask questions
and inform them if you have decided to have
an abortion. If you make this decision later,
you should immediately fill out a 2362
Request for Services form. Women are
scheduled to see the OB provider on an urgent
basis if the procedure can be medically
approved.
After you inform the OB doctor and the FSC
of your decision, they will meet with you to
determine if you fulfill certain criteria,
including being of sound mind and not too far
along in your pregnancy. If you meet the
criteria, the OB doctor will refer your request
to the chief surgeon for final approval.
Pregnant women at CIW do not have to pay
for abortions. The California Department of
Corrections and Rehabilitation (CDCR) will
pay the entire cost. Abortions are performed
at the Planned Parenthood clinic in Riverside.
3
Your right to pregnancy care
You will have regular appointments with the
OB nursing staff throughout your pregnancy.
Unless otherwise indicated by the
doctor, you will have OB visits as
follows:
•
Every four weeks in the first trimester
and up to 24-26 weeks gestation
•
Every three weeks up to 30 weeks
gestation
•
Every two weeks up to 36 weeks
gestation
•
Weekly after 36 weeks gestation up to
delivery
As soon as possible after your pregnancy is
confirmed, you will meet with a dentist and
a dietician. You will also have access to pre-
natal medications.
Other accommodations
When prison staff confirms that you are
pregnant, you will be issued a
Comprehensive Accommodation Chrono.
This Chrono is not a physical card, but a
document in your file that you are pregnant.
This Chrono entitles you to access to
prenatal vitamins as well as two extra
cartons of milk, two extra servings of fruit,
and two extra servings of vegetables daily.
You should be assigned a lower bunk.
Whenever an alarm sounds, you do not have
to drop to the floor; you only have to sit on
the ground.
Under no circumstances can you be
handcuffed behind your back, chained
around your belly, or placed in leg irons.
During a medical emergency, if your
medical provider states that you must be
released from restraints because of medical
need, no restraints may be used at all.
Where will my baby be born?
Although CIW is located in San Bernardino
County, most pregnant women incarcerated
at CIW will give birth at Riverside County
Regional Medical Center, per CIW policy
and preference. It is located at 2650 Cactus
Avenue, Moreno Valley, CA 92555. For
this reason, we only contacted the Riverside
County hospital to get information for this
manual.
However, pregnant CIW women who are
scheduled for a planned caesarean section
(c-section) will give birth at Tri-City
Medical Center in Oceanside, which is in
San Diego County.
It is also possible that you will be brought to
Chino Valley Medical Center (San
Bernardino County), Montclair Hospital
Medical Center (San Bernardino County) or
Corona Regional Medical Center (Riverside
County) to give birth, depending on
individual circumstances.
4
Will someone help me make arrangements for my pregnancy and my baby?
Yes. Within your first week at CIW, a
Family Services Coordinator (FSC) will
meet with you to discuss your options and
answer your questions. The FSC is a social
worker employed by the prison. You have
four options to discuss with the FSC
regarding your pregnancy: abortion,
adoption, transferring to a program where
your baby can live with you, and choosing
someone to act as your baby’s caregiver
while you are in prison. See the section
earlier in this manual that discusses your
right to have an abortion. If none of these
options is desired or possible, then Child
Protective Services (CPS) will intervene and
place your child in foster care.
Adoption
Adoption might be a good option for you if
you do not wish to raise your baby and/or do
not have anyone who can take care of your
baby while you are in prison. Be aware that
adoption permanently ends your rights as a
parent. It can also impact the rights of other
family members to know your child. If,
after careful consideration, you decide to
relinquish (give up) your baby for adoption,
tell the FSC your decision. The FSC can
contact Riverside County to help you set up
an adoption through the state adoption
agency. You can arrange a private adoption
only if you can show that you had a
relationship with an attorney or an adoption
worker before you were admitted to prison.
Living with your baby in a prison facility after you give birth
California has a Community Prisoner
Mother Program (CPMP) that allows some
women in prison to serve their sentences in
places where they can live with their young
children.
1
It is often difficult to transfer to
CPMP housing because there are many
restrictions on who is eligible. Your FSC
may mention the program when you first
meet together. If you communicate that you
are interested in the CPMP, you should be
referred to the Correctional Counselor to
determine your eligibility. The most recent
eligibility form (as of December 2012) is
attached to this manual.
If you think you may be eligible and want to
go to a CPMP program, ask your FSC for
the application forms. Submit your
application to the Correctional Counselor as
soon as possible. You must have medical,
dental, and mental health clearances before
you may transfer to CPMP housing. These
clearances can take a long time. If you are
accepted in the program, but are considered
to be too far along in your pregnancy to be
moved to that facility before giving birth,
you will have to wait until after your baby’s
birth to be moved.
1
At the time this manual was completed, the
only CPMP program available is
“Prototypes” in Pomona.
5
Living with your baby in the community under supervision
Another option is the Alternative Custody
Program (ACP), which allows you to serve
the rest of your sentence while living in your
private home, a community program, or
transitional housing. We have attached the
eligibility requirements from the October
2012 ACP Handbook. It is best to apply for
ACP as soon as possible. Because of the
length of time it takes to be released into this
program, you will probably need to find a
temporary caregiver for your newborn.
Choosing a caregiver for your baby
Most of this manual discusses what to do if
you wish to choose a caregiver for your
baby while you are in prison. During your
first meeting with the FSC, the FSC should
help you think of possible caregivers for
your baby and help you make phone calls to
arrange for a caregiver. In addition to a
caregiver, you will need someone to pick up
your baby from the hospital once you give
birth. These can be, but do not have to be,
the same person. The FSC will help you
make phone calls to arrange for someone to
pick up your baby from the hospital.
You may choose to have the same person
pick up your baby from the hospital and act
as caregiver, or you may choose different
people for these two responsibilities. Just be
sure that the people you call understand
what you expect them to do. Otherwise,
there may be confusion later on at the
hospital. To understand why you might
want to choose one person to pick up your
baby from the hospital and a different person
to act as your baby’s caregiver, see
the section about caregivers who are unable
to travel on page 8 of this manual.
During your initial meeting with the FSC,
you will be given a Newborn Placement
Information Form (NPIF). You MUST
complete a NPIF and give it to your FSC as
soon as possible to ensure that your baby
goes home from the hospital with the person
of your choice. If you cannot fill out the
form at your initial meeting with the FSC,
you can submit it through inmate mail or
submit a request to see the FSC again. The
form does not need to be notarized. You can
find the form attached to this manual. See
the section later in this manual that discusses
how to fill out the form.
After you complete the NPIF, the FSC will
send it to the hospital social worker, give
you a copy, and keep a copy. Once your
baby is born, hospital employees will
contact the person you have named on the
form so that the person knows when to pick
up your baby from the hospital.
What should I think about when I am choosing someone
to take care of my baby while I am in prison?
General considerations
It is very important that you choose a
caregiver for your baby whom you can trust.
The caregiver should have plenty of time
and patience to love and care for your baby.
Your baby’s caregiver also needs to have a
stable income to support your baby and keep
him or her fed and clothed. Although no
two people have exactly the same parenting
6
style, your baby’s caregiver generally should
share your views about what it means to be a
good parent. It would be ideal for you and
your baby’s caregiver to share similar values,
especially regarding education,
religion, and similar issues. Finally, it is
crucial that you choose a caregiver for your
baby who has the desire and the ability to
keep the relationship between you and your
baby strong. Your baby’s caregiver will
play a vital role in helping you maintain
your family unity, and you should keep this
in mind as you carefully consider your
choice of a caregiver.
Choosing a relative or a nonrelative
One advantage of choosing a relative to care
for your baby is the availability of
government benefits. Only certain relatives
qualify for TANF (Temporary Assistance
for Needy Families, a federal program) or
CalWORKS (California Work Opportunity
and Responsibility to Kids, the California
version of TANF). Eligible relatives
include: grandparents, aunts, uncles,
siblings, first cousins, nephews, nieces; any
of those persons just listed who are
described by the prefixes half, grand, great,
or step; or the spouse of any person named
above, even after the marriage has been
terminated. You might want to keep this in
mind when you choose a caregiver for your
baby.
The Newborn Placement Information Form
asks that you choose a relative to care for
your baby. The form defines relatives as:
•
All birth relatives including those whose
status is preceded by the words “step,”
•
“great,” “great-great,” or “grand”;
•
The spouse of any of the people listed
above even after the marriage has ended
•
by death or divorce;
•
Any person listed above, who is related
to the child’s half-brother or half-sister.
CIW does not run a background check on
the person you name on this form, nor does
CIW verify that he/she is actually related to
you. Thus, it is possible to name a
nonrelative on the form as the person who
will care for your baby. Whether a relative
or a nonrelative, you should choose this
person carefully.
Filling out the Newborn Placement Information Form
You will notice that the Newborn Placement
Information Form provides spaces at the
bottom for you to list two people who can
“care for” your baby. Despite the confusing
language, CIW is simply asking you to list
two people who have your permission to
pick up your baby from the hospital. If
one of those people is not available after
your baby is born, the other person can step
in and pick up your baby from the hospital.
CIW and the hospital are concerned about
releasing your baby to the right person at the
hospital. CIW will not check to make sure
that the person who picks up your baby from
the hospital continues to take care of your
baby. After your baby leaves the hospital
with a person you have named on the
Newborn Placement Information Form, your
baby could be cared for by someone else
while you are in prison. Be aware that if
your designated person passes your baby to
another person, your baby could end up
being cared for by someone you did not
intend.
7
What to do if your baby’s caregiver is unable to travel
You might have a caregiver in mind who
cannot pick up your baby from the hospital
because of the caregiver’s age, disability,
distance from the hospital, or other reasons.
If your desired caregiver cannot pick up
your baby, you need to name someone else
on the Newborn Placement Information
Form who is able to pick up your baby.
Your desired caregiver can step in and care
for your baby after a person you name on
the Newborn Placement Information Form
picks up your baby from the hospital.
Formal legal arrangements
Depending on how long you will be in
prison and other factors, you may want to
make formal legal arrangements with your
baby’s caregiver. See the sections later in
this manual that discuss Temporary Custody
Agreement/Power of Attorney, legal
guardianship, and adoption by your baby’s
caregiver.
When does Child Protective Services get involved?
Child Protective Services (CPS) gets
involved if it is contacted by the hospital
where you give birth. The hospital will call
CPS if there are problems or concerns with
the caregiver you have chosen. CPS may
also get involved if you have had a prior
CPS case.
To avoid CPS involvement, you should try
to make sure that the people you name on
the Newborn Placement Information Form
have as clean criminal and CPS records as
possible. Also, you should make sure the
people you name to pick up your baby from
the hospital are sober and competent when
they arrive at the hospital. They must bring
necessary baby supplies to the hospital,
including an infant car seat. Also, it is
important that your other loved ones know
and understand whom you have chosen to
pick up your baby from the hospital so that
there is no confusion. Finally, make sure it
is clear on paper, especially on the Newborn
Placement Information Form, whom you
have chosen to pick up your baby from the
hospital.
There is more information about CPS on
pages 12-14 of this manual.
What if I do not have anybody to choose as my baby’s caregiver?
If you cannot name someone to pick up and
take care of your baby on the Newborn
Placement Information Form, CPS will step
in to claim your baby at the hospital. See
the sections later in this manual that describe
what happens when CPS becomes involved
and what actions you should take.
Can I request that someone be present when I give birth at the hospital?
Yes, unless you give birth by a planned or
scheduled c-section. The person you request
must be an approved visitor at CIW and pass
a DOJ security clearance. Security
clearances can take up to four months, so be
sure to plan ahead.
8
You will also have to fill out other
paperwork for approval by the warden. The
FSC can provide you with this paperwork.
In this paperwork, your support person may
be referred to as a “birth coach.” However,
he/she is not expected to have any training
or expertise in child birth. Ideally, you
should complete the forms required to have
a support person present at the birth before
you are 7 months into your pregnancy, as
these documents must be sent to your
support person, signed by him/her, and
returned to the prison for approval by the
warden.
If the person you wish to be present at the
birth is on probation for a minor issue,
he/she will need a letter of permission from
the probation officer. If your birth coach is
on parole, he/she will need to discharge the
parole number. Decisions regarding who is
or is not an acceptable support person are
made on a case-by-case basis. You are
highly encouraged to be truthful in your
application.
If the warden signs off on your request, the
Watch Commander’s Office will notify your
support person when you are in active labor.
What will happen when it is time for me to have my baby?
If doctors decide ahead of time that you will
need caesarean surgery (a “c-section”), they
will schedule the surgery with Tri-City
Medical Center in Oceanside. You will not
be told of your surgery date until the day the
surgery is scheduled to happen. A CDCR
state car will take you to the hospital.
If no surgery is planned, when you go into
labor, CIW will treat the situation like a
medical emergency: medical staff will be
notified to assist you and an ambulance or
the fire department will take you to the
hospital. Although prison staff will request
that you be taken to Riverside County
Regional Medical Center, the paramedics
could instead take you to Chino Valley
Medical Center, Corona Regional Medical
Center, or Montclair Hospital Medical
Center, depending on individual
circumstances.
It is the prison staff’s responsibility to make
sure that all copies of your pregnancy
paperwork go with you to the hospital. If
you have prepared a Temporary Custody
Agreement/Power of Attorney form and
have not given it to your baby’s caregiver,
you should bring a completed copy of it to
the hospital for him or her.
Before leaving CIW for the hospital to give
birth, you can ask a friend inside to call the
person who is supposed to pick up your
baby. Though the hospital will also call this
person after you give birth, getting a friend
to call beforehand can be helpful, especially
if you know that your caregiver will need
extra time to get to the hospital. Your
caregiver can phone the hospital to inform
them that she or he is on the way. However,
prisoners are confidential patients, so the
hospital will not be able to tell your
caregiver anything about your status
(delivered/undelivered), or even confirm that
you are in the hospital. Instead, the hospital
social worker will call your
caregiver as soon as possible after your
delivery. The person you select has 24
hours to pick up your baby after the
newborn is ready to be discharged.
Whoever picks up the baby from the
hospital should bring two forms of picture
identification.
9
How will I get to the hospital?
You will be taken to the hospital according
to your code number. If you are having a
planned birth or a c-section, a state car will
take you to the hospital. This is known as a
“Code 1.” If the birth is not scheduled
beforehand, you will be taken to the hospital
by an ambulance (“Code 2”) or by the fire
department (“Code 3”). Prison staff will
ride with you to the hospital.
On your way to the hospital while in labor,
and at the hospital during labor, delivery and
recovery, you may not be cuffed at the
wrists, ankles, or both. The only exception
is if shackling is necessary for the safety or
security of yourself or others.
Even then, if a medical professional states
that your restraints must be removed for
medical reasons, they must be removed.
What does the hospital social worker do?
At the hospital, a social worker will meet
with you to discuss your plan for your baby.
Because the Newborn Placement
Information Form has spaces for you to
name two people to pick up your baby from
the hospital, the social worker will ask who
your first choice is and try to contact that
person once your baby is born. If the social
worker cannot reach your first choice, she
will contact the other person listed on the
form so that someone will arrive to take
your baby home from the hospital.
If the person who is picking up your baby
lives very far from the hospital, you should
inform the hospital of this fact. Otherwise,
the hospital may not give your caregiver
enough time to get to the hospital before
deciding that your baby is “abandoned” and
calling CPS. The hospital and CPS are
usually willing to work with a caregiver who
must travel a long distance, as long as the
caregiver is clear about needing extra travel
time. If the caregiver is running late, he or
she should call the hospital as soon as
possible.
The hospital social worker will also keep
you aware of any CPS involvement. The
hospital social worker will notify CIW’s
Family Services Coordinator when your
baby is born.
The hospital social worker gives the person
who picks up the baby from the hospital a
useful information package. It includes
information on how to access the baby’s
birth records, contact the courthouse, apply
for CalWorks, and obtain money and
necessary items such as diapers for the baby.
The person who picks up the child will also
be provided with his/her own social worker.
What forms will I need to fill out at the hospital?
Birth certificate
Every new mother is given a birth certificate
worksheet when she is admitted to the
mother-baby (post-partum) unit. The
worksheet has to be completed before
discharge so that you can review and sign
the formal birth certificate. If you need
assistance, the hospital social worker or a
nurse may help you complete the worksheet.
10
The designated person who picks up your
baby is given a complimentary birth
certificate (which has the baby’s footprints)
and contact information for the County
Recorder’s office. They will automatically
receive a copy of the birth certificate six
weeks after the child’s birth, unless the child
was born on prison grounds.
If you would like a copy of your child’s
birth certificate or if your child is born on
prison grounds, you will have to fill out an
application and request one. The certificate
is available from either the State of
California Office of Vital Statistics or the
County Recorder in the county where your
child was born. In either case, you will have
to fill out an application, get it notarized,
and mail in $16 for each certified copy
requested. The state application form is
included at the end of this manual. Here are
the addresses:
Declaration of Paternity
If you are married, the law presumes that your
husband is the father of your baby, so you will
not need to fill out a Declaration of Paternity. If
you are unmarried, you may request that the
Declaration of Paternity be completed. The
hospital social worker can help you fill out the
form. For it to be valid, both parents must sign
the form. The hospital social worker will
contact the man you name as the father and
inform him of the baby’s birth. If he agrees he is
the father, the social worker will arrange for the
form to be completed at the hospital. If possible,
it is best that the form be completed: it is easier
for the named father to assert his parental rights,
it is easier for you and others to enforce the
named father’s parental responsibilities, and it is
the only way to get the father’s name on the
birth certificate if you are unmarried.
If the man you have identified is unavailable, if
he questions whether he is the father, and/or
requests a paternity test, or if you do not provide
his name, the Declaration of Paternity is not
completed. In this case, you or the father will
need to take additional steps later in family court
to establish his parental rights and
responsibilities. A copy of the Declaration and
instructions are included at the end of this
manual.
Will I be able to spend time with my baby?
Like any mother, you should be allowed to
spend time with, and care for, your baby
once he or she is born. However, if you
have ever had a CPS case, CPS might
require you to be supervised during your
time with your baby. Also, if your baby has
to be transferred to a different hospital
because of special medical needs, you may
not be able to spend much time with him or
her.
11
Riverside County Recorder
2724
Gateway Drive
Riverside, CA 92507
San Bernardino County Recorder
222
West Hospitality Lane
San Bernardino, CA 92415
San Diego County Recorder
P.O.
Box 12150
San Diego, CA 92112-4750
State Office of Vital Statistics
P.O.
Box 730241
Sacramento, CA 94244-0241
The maximum amount of time that you may
stay in the hospital is 72 hours. It is highly
unlikely that you will stay for 72 hours
unless you give birth by caesarean surgery
or you need serious medical attention. If
you give birth vaginally, you may leave the
hospital in as little as 24 hours.
Unfortunately, there is a chance that you
will be returned to prison before your baby
leaves the hospital. However, CDCR will
keep a record of the person who picks up
your baby from the hospital, and you can
ask the FSC for this information.
What happens if my baby has special medical needs?
Babies born at Riverside County Regional
Medical Center who are premature or who
need special medical attention may be
treated in that hospital’s Neonatal Intensive
Care Unit. If your baby needs to be moved
from the hospital of birth to a facility that is
better able to cope with his or her specific
needs, you will be notified either by the
hospital social worker (if you have yet to be
discharged from the hospital) or by the
prison social worker (if you are already back
at CIW). Babies with special needs are
commonly sent to Children’s Hospital of
Orange County or Loma Linda Hospital in
San Bernardino. While your baby is still in
the hospital, you can call the hospital weekly
to check on the health of your baby. These
calls are facilitated by the FSC. If you are
undergoing methadone maintenance at the
time of the baby’s birth, your baby may need
to stay in the hospital for an extra three
months to detox.
When will the hospital call CPS about my baby?
The hospital social worker will call CPS if
there is no appropriate caregiver to pick up
your child and/or if you have a prior case
with CPS regarding a different child.
Most CIW women give birth at the
Riverside County Regional Medical Center
(RCRMC). After your baby is born there,
the hospital social worker will research the
backgrounds of the people you listed on the
NPIF to find out if they have any
outstanding warrants or drug use history.
The social worker will also call and
interview them about their ability and desire
to take care of the baby. If the hospital
social worker determines that neither of the
people you have listed on the NPIF would
be a suitable caretaker, she will notify you
that someone else needs to be found. If you
have no other suitable caregiver to suggest,
the social worker will contact the CPS
hotline. We assume that the other hospitals
where you may give birth use similar or
identical procedures.
There are several factors that can contribute
to the hospital contacting CPS, such as:
•
A person you name does not arrive to
take your baby home, and/or someone
else arrives who is not named on the
form;
•
A person you name arrives at the
hospital intoxicated or in a state that the
hospital thinks is unsafe for your baby;
•
A person you name does not seem
prepared or lacks the resources to take
care of a child;
•
You and the person you name do not
appear to recognize one another;
•
The hospital social worker learns that
you or a person you name have a history
with CPS;
12
•
The hospital social worker learns that
you or the person you name have had
parental rights terminated with respect to
a different child; or
•
Your baby tests positive for illegal drugs
upon birth, or the hospital determines
that you have used illegal drugs in the
last 30 days.
The hotline will forward the hospital’s call
to the local CPS office for the county where
the hospital is located. For example, if the
Riverside County Regional Medical Center
social worker calls the CPS hotline, he or
she will deal with the Riverside CPS. If
CPS is contacted, CPS will decide whether
your baby will go home with a person of
your choosing or whether CPS will take
authority over your baby.
Is there anything that will automatically cause CPS to take my baby?
Yes, CPS automatically will take your baby
if you have an open case with the child
welfare system or if your baby is considered
to be “abandoned.” Abandonment can
happen in a few ways:
•
You do not name anyone to care for your
baby on the NPIF;
•
No one arrives at the hospital to take
your baby home;
•
A person you name on the NPIF arrives
at the hospital more than 24 hours after
your baby is ready for discharge (usually
about two days after birth). If your
designated caregiver needs extra time to
get to the hospital, s/he should let the
hospital know in advance.
If any of these situations occur, or if the
hospital’s local CPS agency decides that you
have not provided a suitable caregiver, that
agency will contact the CPS office from
your “county of origin.” Your county of
origin is the county where you lived before
you were arrested. Other counties will not
have jurisdiction over your baby’s CPS case.
If Riverside County CPS has your baby
temporarily, it is only as a courtesy to your
county of origin.
If CPS intervenes and takes my baby, what happens next?
Once the CPS from your county of origin is
contacted, it will likely come to the hospital,
pick up your baby, return your baby to its
county, and place your baby in an
emergency shelter or temporary foster care.
If no one can claim your baby in 48 hours,
CPS must file papers in the juvenile court in
your county of origin to make your baby a
dependent of the court.
Act quickly to claim your baby
Once the hospital releases your baby to CPS,
act as quickly as possible to call a relative or
have a relative call CPS. No one will be
able to receive your baby from CPS until
CPS conducts an “emergency assessment”
and approves the person who will take care
of your baby while you are in prison. An
emergency assessment includes a criminal
background check, a home visit, and an
investigation of any alleged abuse or neglect
caused by any adult in the home where the
baby will live. The person who arrives at
CPS to request custody of your baby should
bring any possible proof to establish his or
13
her relationship to your baby. CPS must
release the baby to a responsible and
qualified relative willing to provide care,
except under certain unusual circumstances.
How your baby might become a dependent of the court
If CPS has not released your baby to a
relative or other person, it will file a petition
to make your baby a dependent of the court.
You have the right to notice of all court
hearings involving your baby. A detention
hearing will be held three days after your
child is taken into custody. At the detention
hearing, the court will decide whether CPS
should release your baby, or whether your
baby should stay with CPS until the next
hearing. If you do not have a lawyer to
represent you in your baby’s CPS case, the
court will appoint one for you at the
detention hearing. You also have the right
to appear in court, either in person or by
telephone.
At the detention hearing, if the judge decides
that your baby should stay with CPS, there
will be a jurisdiction hearing scheduled
within 15 court days. If the judge releases
your child to a relative, the jurisdiction
hearing will be scheduled within 30 days.
You will be encouraged to put together a
case plan for the care of your child before
the jurisdiction hearing.
At the jurisdiction hearing, the judge will
decide whether to declare your baby a
dependent of the court. If the judge declares
your baby a dependent of the court, the court
will take legal custody of your baby and
decide where and with whom your baby will
live. At this point, if CPS releases your baby
to a relative, the relative can get
financial help and services through CPS.
For more information on what happens in
juvenile dependency court, including foster
care, reunification and other permanent
plans, please see the “Incarcerated Parents
Manual” produced by Legal Services for
Prisoners With Children, June 2010 edition,
pages 8-20. This manual is available in the
prison law library, or you can write to us to
request a free copy.
What happens after I return to prison?
Seven to 14 days after you return to CIW
from the hospital, you will have a post-
delivery interview with the FSC. During this
interview, you will be able to call your
child’s caregiver. In this phone call, you can
find out if he or she needs information about
available community and funding resources
to help support your child, such as MediCal.
If your child is with CPS, you will be able to
contact CPS to determine the status of your
baby. During this meeting with the FSC,
you can also discuss your visitation
prospects with your child and the Temporary
Custody Agreement/Power of Attorney
discussed below.
14
How do I make more formal legal arrangements for my baby?
Temporary Custody Agreement/Power of Attorney
If you choose a caregiver for your baby, you
might consider completing a Temporary
Custody Agreement/Power of Attorney
form. This form is usually notarized, but can
have two witnesses. It
allows the caregiver
to make decisions about
your child for you.
The form is not a court
order. You can
revoke it in writing at any
time. For
instance, you can revoke the
Power of
Attorney when you are released from
prison. Make sure you file a copy of
your
completed Temporary Custody
Agreement/Power of Attorney form with the
prison so that your baby’s caregiver can
bring your baby to visit with you. Give
another copy of the completed form to your
baby’s caregiver and keep one for yourself.
Copies of these forms are attached here.
Legal guardianship
Depending on the length of your sentence
and other factors, you may want your baby’s
caregiver to have legal guardianship status.
Legal guardianship is a court order that
gives legal and physical custody and control
of your child to the guardian. It suspends
but does not terminate your rights regarding
your baby. Both relatives and nonrelatives
may be legal guardians. Once the court
appoints a legal guardian, the guardian has
full legal responsibility for your baby,
including making educational and medical
decisions. Legal guardianship orders are
given in either probate court or, if CPS
becomes involved, in juvenile dependency
court.
Be aware that when you wish to end your
caregiver’s legal guardianship, you will have
the burden of proving to a court that your
baby should be with you. This can be a
difficult legal battle. Much depends on your
relationship with your baby’s caregiver. If
you only have a short prison sentence, it is
likely not worthwhile to set up a legal
guardianship.
There is generally no requirement that you
set up a legal guardianship with your baby’s
caregiver. However, a court may grant your
baby’s caregiver legal guardianship if (1)
your baby becomes a dependent of the court
or if (2) the caregiver petitions for
guardianship in probate court, even over
your objection. See the section above on
how your baby might become a dependent
of the court when CPS intervenes.
Adoption by your baby’s caregiver or guardian
Voluntary adoption: Depending on the
length of your sentence and other factors,
you may want your baby’s caregiver to
adopt your baby. Because court-approved
adoptions are permanent, you should be
absolutely sure about this choice. Adoption
ends your rights to your child permanently.
Depending on your relationship with your
baby’s caregiver and the way that
relationship changes while you are in
prison, adoption may mean that you never
see your baby again. You have a right to
both a counselor and an attorney to help
you make your decision about adoption.
You also have a right to change your mind
about the adoption by revoking your
15
consent in writing within 30 days of
signing the adoption consent papers.
Involuntary adoption: Be aware that your
child’s caregiver or guardian can petition
the court for adoption without your
consent. If this happens and you object,
you can oppose the adoption by refusing to
sign consent forms, asking for an attorney
and attending any court hearing.
What should I do to make sure my baby can visit me at CIW?
To get a visit with your baby, you will have
to get your baby and the person who brings
your baby approved. Your adult visitor has
to be approved like all other visitors. The
clearance process for adult visitors takes 3 to
4 months, so it is best to plan ahead.
To get your baby admitted to the prison for
visiting, the adult visitor must present a copy
of your baby’s birth certificate. The
complimentary birth certificate issued by the
hospital may be used for up to 6 months
after you give birth. After 6 months, you
will need to have a certified copy of the birth
certificate.
You also have to show that the person with
legal custody of your baby gives permission
for the visit. If the adult who brings your
child to visit is the father as shown on the
birth certificate, the birth certificate is all
that he needs to bring. If the adult who
brings your child to visit is another person
with legal custody, he or she must bring the
legal document showing custody. This
could be a court order, letters of
guardianship, or Power of Attorney.
If your child is brought by an adult who is
not the person with legal custody, then the
person with legal custody will have to fill out
a notarized “Written Consent for Minor
Visitation Authorization Form” giving
permission for your visitor to bring the baby
to see you. (This form must be updated each
year.) That visitor must bring the “Written
Consent for Minor Visitation Authorization
Form” and the legal document showing
custody at the time of the visit. A copy of
16
the Written Consent Form is attached to this
manual.
If there is no court order or Power of
Attorney giving someone custody of your
baby, and the adult visitor is not the father
on the birth certificate, the prison may
require you to fill out the Temporary
Custody Agreement/Power of Attorney form
(and have it notarized) giving the visitor
temporary custody in order for the visitor to
bring your baby to see you.
If your child is in foster care, you can still
visit with him or her, but you will need to
obtain a court order for visitation. Either a
CPS worker or a foster parent or could bring
your baby to you. If your child is being
transported by a CPS worker, the worker
must bring a copy of the court order and an
original birth certificate. If your child is
being transported by a foster parent, that
person must bring the birth certificate, the
court order and also a letter from CPS
authorizing this transportation.
If your child is in foster care, you may also
wish to explore CIW’s Enhanced Visiting
Program. This program enables you to visit
with your child for one to two hours every
week or month. Visiting takes place in a
more child-friendly environment in a
building that is separate from the regular
visiting area. A court order for visitation is
required for this program. Ask the FSW
about this program if you think you might be
eligible.
It is very disappointing when a visitor who
travels all the way to the prison is turned
away and unable to visit because the
paperwork is not in order. We suggest that
you or your adult visitor double check with
prison officials in advance of a scheduled
visit that the paperwork you have will allow
you to visit with your child.
If your baby’s caregiver refuses to bring
your baby to visit with you, you may
petition a court to obtain and enforce
visitation rights through a visitation order.
Make sure to request contact visits so that
you can hold your baby. Visitation is your
and your baby’s right, and state agencies
generally encourage visiting between
parents in prison and their children. For
more information about how to obtain a
court order for visits, see LSPC’s manual,
“Child Custody and Visiting Rights for
Incarcerated Parents.”
Final thoughts
We at LSPC sincerely hope that this manual
has been helpful to you. Thank you for
taking the time to read it. If you need more
information on parenting while you are
imprisoned, you may find our “Incarcerated
Parents Manual” helpful, as well as other
resources available to you in the CIW
library. If you know of any way that we can
improve this manual, we invite you to
contact us. We wish you the very best as
you make whatever arrangements you feel
are right for you and your family during this
important time in your life.
17
PRISON LAW OFFICE
General Delivery, San Quentin CA 94964
Telephone (510) 280-2621 Fax (510) 280-2704
www.prisonlaw.com
Your Responsibility When Using the Information Provided Below:
When putting this material together, we did our best to give you useful
and accurate information because we know that prisoners often have trouble
getting legal information and we cannot give specific advice to all prisoners
who ask for it. The laws change often and can be looked at in different ways.
We do not always have the resources to make changes to this material every time
the law changes. If you use this pamphlet, it is your responsibility to make sure
that the law has not changed and still applies to your situation. Most of the
materials you need should be available in your institution’s law library.
INFORMATION ABOUT
THE CDCR’S ALTERNATIVE CUSTODY PROGRAM (ACP)
(Updated December 2016)
We are sending you this letter because you have asked for information about the CDCR’s
Alternative Custody Program (ACP). We are unable to send individual responses to every who
contacts us about the ACP, but be hope that this letter will help answer your questions.
The Alternative Custody Program (ACP) allows some prisoners to serve part of their
sentence in a residential home, residential drug-treatment program, or transitional care facility.
(Penal Code § 1170.05; 15 CCR § 3078.1.)
The ACP was originally available only to female prisoners. However, in September
2015, a federal court found that excluding male prisoners from the ACP violated the
constitutional guarantee of equal protection, and the court ordered the CDCR to expand the
program to allow male prisoners. (Sassman v. Brown (E.D.Cal. 2015)99 F.Supp.3d 1223.) The
CDCR has now amended the ACP regulations and accepts applications from and approves
certain male prisoners to go to the ACP.
To be considered for ACP placement, a prisoner must have no more than 12 months and
no less than 45 days of state prison sentence left to serve by the time of the ACP placement. (15
CCR § 3078.2(b).) The prisoner must not have a current conviction for a serious or violent
felony, a current or prior conviction that requires sex offender registration, a history of escape
within the past 10 years, or be deemed at high risk of committing a violent offense. (Penal Code
§ 1170.05(d); 15 CCR § 3078.2(c); 15 CCR § 3078.3(a).) The CDCR rules also bar prisoners
from ACP placement for other reasons including an active or potential criminal or immigration
hold, an active restraining order, Level A-1 through Level C in-prison misconduct in the last 24
months (except for possession of alcohol), validation as an active or inactive STG-I member or
associate, current close or max custody status, and SHU or PSU placement in the last 12 months.
(15 CCR § 3078.2(c); 15 CCR § 3078.3(a).) There are other factors that may exclude a person
Board of Directors
Penelope Cooper, President Michele WalkinHawk, Vice President Marshall Krause, Treasurer
Christiane Hipps Margaret Johns Cesar Lagleva
Laura Magnani Michael Marcum Ruth Morgan Dennis Roberts
Director:
Donald Specter
Managing Attorney:
Sara Norman
Staff Attorneys:
Mae Ackerman-
Brimberg
Rana Anabtawi
Steven Fama
Alison Hardy
Sia Henry
Corene Kendrick
Rita Lomio
Margot Mendelson
Millard Murphy
Lynn Wu
Prison Law Office page 2
Information re: Alternative Custody Program (revised 12/2016)
from ACP placement, but that are considered on a case-by-case basis; these include being
validated as an STG II member or associate, having a current or prior conviction for child abuse,
stalking or arson, and having failed in a prior ACP placement. (15 CCR § 3078.3(b).
Importantly, ACP placement can be denied if there simply is no appropriate facility space
available. (15 CCR § 3078.3(b)(5).)
A psychiatric or medical condition that requires ongoing care is not a basis for excluding
a prisoner from eligibility for participation in the ACP. (15 CCR § 3078.3(c).)
To be considered for ACP placement, a prisoner must sign and submit a CDCR Form
2234 ACP Application and Voluntary Agreement. (15 CCR § 3078.4(a).) The procedures for
processing a request for ACP placement are set forth in the CDCR’s regulations. (15 CCR §
3078.4.) The regulations do not provide for any set deadline for the CDCR to process an ACP
application. However, if the CDCR deems a prisonerto be potentially eligible for the ACP,
prison staff are supposed to take no more than 30 calendar days to prepare an Individualized
Treatment and Rehabilitation Plan (ITRP) describing the activities and services needed for the
particular prison. (15 CCR § 3078.4(b).) The ITRP and other information will then be presented
to an Institution Classification committee (ICC), which will decide whether or not to recommend
ACP placement. (15 CCR § 3078.4(c).)
Prisoners who are placed in the ACP will receive credit for actual time served and the
same conduct credits that they would have received if they had served the time in prison. (Penal
Code § 1170.05(a); 15 CCR § 3078.1(c).) Participants in the ACP are supervised by a parole
agent and can be subjected to searches, electronic monitoring, and other conditions. (Penal Code
§ 1170.05(g); 15 CCR § 3078.5.) ACP participants can be returned to custody with or withour
cause for any reason including no longer meeting the program criteria, not complying with the
conditions of the program, failure of the electronic monitoring device, new criminal activity, or
when the available programs can no longer meet the participant’s needs. A participant can also
ask to be removed from the ACP. (15 CCR § 3078.6.)
In addition to the ACP, the CDCR has other programs through which prisoners with
short amounts of time left to serve may be placed in the community. These programs include the
Community Prisoner Mother Program (CPMP), the Custody to Community Transitional Re-
entry Program (CCTRP), and the Male Community Reentry Program (MCRP).
If you think you are eligible for the ACP (or if you want to learn more about the other
community-based programs), please contact your correctional counselor. If you have problems
getting prison officials to consider you for ACP placement, or if you believe you have been
unfairly denied ACP placement, you should file an administrative appeal. Likewise, if you are
placed in the ACP and have complaints about your treatment or conditions, or if you are unfairly
removed from the ACP, you should file an administrative appeal. A free manual on how to
prepare and file administrative appeals is available from the Prison Law Office or at
www.prisonlaw.com.
If you pursue an administrative appeal through the Third (Director’s) Level and are not
satisfied with the result, please send a copy of your appeal and all responses to the Prison Law
Office. At that point, the Office attorneys will review your appeal and determine whether we
can provide assistance or information on further legal actions.
D D
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State of California – Health and Human Services Agency California Department of Public Health
APPLICATION FOR CERTIFIED COPY OF BIRTH RECORD
PLEASE READ THE INSTRUCTIONS ON PAGE 2 BEFORE COMPLETING THIS APPLICATION
California law (Health and Safety Code Section 103526), permits only authorized individuals as listed on the application to receiv
e
certified copies of birth records. Those who are not authorized by law to receive an authorized certified copy will receive a certified
informational copy with the legend, “INFORMATIONAL, NOT A VALID DOCUMENT TO ESTABLISH IDENTITY.”
Please indicate the type of certified copy you are requesting:
I am requesting a Cert
ified AUTHORIZED copy I am requesting a Certified INFORMATIONAL copy
NOTE: Both documents are certified copies of the original document on file with the California Department of Public Health – Vital Records
(CDPH-VR). With the exception of the legend and redaction of signatures and Social Security Number, the documents contain the same
information.
To receive an AUTHORIZED copy, you MUST INDICATE YOUR RELATIONSHIP TO THE REGISTRANT below. To receive a certified copy, the
applicant must sign a sworn statement that he or she is authorized to receive the certified copy. The Sworn Statement MUST BE
NOTARIZED unless you are a member of a law enforcement agency or a representative of a state or local government agency.
RELATIONSHIP:
Registrant
(Name on Certificate) Child/Sibling of Registrant
Grandparent/Grandchild of Registrant Spouse/Registered Domestic Partner of Registrant
Authorized by Court Order
(Include copy of the court order.) Attorney Representing Registrant or Registrant’sEstate
Law Enforcement/Govt. Agency
(Conducting Official Business) Attorney/Licensed Adoption Agency (Under CA Family Code § 3140 or 7603)
Parent/Legal Guardian of Registrant (Legal guardian must provide documentation.)
Power of Attorney/Executor of the Registrant’s Estate (Include a copy of the power of attorney or supporting documentation
identifying you as executor.)
APPLICANT INFORMATION (PRINT OR TYPE) Today’s Date:
Agency Name (If Applicable) Agency Case Number Inmate ID Number
Name of Person Completing Application Signature of Applicant Purpose of Request
☐ Check this box
for CNPR Request
Mailing Address – Number, Street, and Unit # (if applicable) Amount Enclosed – DO NOT SEND CASH
$ _ Check $ Money Order
Number of Copies
City Name of Person Receiving Copies if Different from Applicant
State/Province
ZIP Code
Country
Mailing Address for Copies if Different from Applicant
Daytime Telephone Number
( )
Email Address City State ZIP Code
BIRTH RECORD INFORMATION (PRINT OR TYPE) Adopted:
No
Yes (If Yes, see #4 on Page 2)
Complete the information below as shown on the birth record, to the best of your knowledge.
FIRST Name MIDDLE Name LAST Name
City of Birth (must be in California) County of Birth
Date of Birth – MM/DD/YYYY (If unknown, enter approximate date)
FIRST Name Mother Father Parent MIDDLE LAST
(Birth/Before Marriage/Domestic Partnership)
FIRST Name Mother Father Parent MIDDLE LAST (Birth/Before Marriage/Domestic Partnership)
FEE: $25 PER COPY (PAYABLE TO CDPH VITAL RECORDS)
Submit Check or Money Order – Do Not Send Cash
Check/Money Order Enclosed
Notarized Sworn Statement Enclosed (if applicable)
You may view current processing times at www.cdph.ca.gov
BIRTH
VS 111 (01/18) Page 1 of 3
INFORMATION:
Birth records have been maintained by the California Department of Public Health – Vital Records (CDPH-VR) since July 1, 1905.
The name required on Vital Records (see Items 1C, 6C, 7C, 9C, and 12C) is the name given at birth, or a name received through adoption, court-
ordered name change, or naturalization. AKAs (Also Known As) and assumed names cannot be entered as the legal name on the birthrecord.
INSTRUCTIONS:
1.
2.
3.
4.
5.
6. SWORN STATEMENT:
7.
8.
ONLY individuals who are authorized by Health and Safety Code Section 103526 can obtain a Certified Copy of a birth record to establish
identity of the registrant (person listed on the certificate). Page 1 identifies the individuals who are authorized to make the request. All
others may receive a Certified Informational Copy which will be marked, “Informational, Not a Valid Document to Establish Identity.”
Confidential Information on Birth Record: some individuals have special needs for a birth certificate that contains the confidential
information provided at the time the birth record was prepared. This confidential information may be used to establish ethnicity, to provide
health background, or for other personal reasons. For information on how to obtain a birth certificate containing the confidential
information, please refer to the Birth Record section of the CDPH-VR website at: www.cdph.ca.gov. Only specific individuals may obtain
confidential copies.
Complete a separate application for each different birth record requested.
Complete the Applicant Information section on Page 1 and provide your signature where indicated. In the Birth Record Information
section, provide all the information you have available to identify the birth record. If the information you furnish is incomplete or
inaccurate, CDPH-VR may not be able to locate the record.
If the registrant has been adopted, make the request in the adopted name. If you are requesting a copy of the original birth certificate,
you must provide a court order releasing the original sealed record.
If you require documentation that a birth record does not exist, check the box for CNPR (Certificate of No Public Record) Request on the
application.
• The authorized individual requesting the certified copy must sign the attached Sworn Statement, declaring under penalty of perjury
that they are eligible to receive the certified copy of the birth record and identify their relationship to the registrant – the
relationship must be one that is identified on Page 1. Only one sworn statement is required for multiple records.
• If the application is being submitted by mail, the Sworn Statement must be notarized by a Notary Public. To find a Notary Public, see
your local yellow pages or call your banking institution. Law enforcement and local and state governmental agencies are exempt
from the notary requirement.
• A Sworn Statement notarized by a foreign notary must have an apostille attached. An Apostille is a certificate that authenticates a
document for use in another country. Foreign notarizations obtained from an Ambassador, Minister, Consul, Vice Consul or
Consular Agent of the United States, or from a Judge of Court of record having a seal in a foreign country do not require an apostille.
• You do not have to provide a Sworn Statement if you are requesting a Certified Informational Copy of the birth record.
Submit $25 for each copy requested. If no birth record is found, the fee will be retained for searching for the record (as required by law)
and a “Certificate of No Public Record” will be issued to the applicant. Indicate the number of copies you want and include the correct
fee(s) in the form of a personal check or postal or bank money order (International Money Order for out-of-country requests) made
payable to CDPH Vital Records. PLEASE SUBMIT CHECK OR MONEY ORDER – DO NOT SEND CASH (CDPH cannot be held responsible for
fees paid in cash that are lost, misdirected, or undelivered).
Mail completed applications with the fee(s) to:
California Department of Public Health
Vital Records – MS 5103
P.O. Box 997410
Sacramento, CA 95899-7410
(916) 445-2684
BIRTH
Page 2 of 3
VS 111 (01/18)
-------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
State of California – Health and Human Services Agency California Department of Public Health
SWORN STATEMENT
I, _, declare under penalty of perjury under the laws of the State of California,
(Applicant’s Printed Name)
that I am an authorized person, as defined in California Health and Safety Code Section 103526 (c), and am eligible to receive a
certified copy of the birth, death, or marriage certificate of the following individual(s):
Applicant’s Relationship to Person Listed on Certificate
Name of Person Listed on Certificate
(Must Be a Relationship Listed on Page 1 of Application)
(The remaining information must be completed in the presence of a Notary Public or CDPH Vital Records staff.)
Subscribed to this _ day of , 20 _, at , _.
(Day) (Month) (City) (State)
(Applicant’s Signature)
Note: If submitting your order by mail, you must have your Sworn Statement notarized using the Certificate of Acknowledgment
below. The Certificate of Acknowledgment must be completed by a Notary Public. (Law enforcement and local and state
governmental agencies are exempt from the notary requirement.) Only one sworn statement is required for multiple records.
CERTIFICATE OF ACKNOWLEDGMENT
A notary public or other officer completing this certificate verifies only the
identity of the individual who signed the document to which this certificate is
attached, and not the truthfulness, accuracy, or validity of that document.
State of )
County of )
On before me,
(insert name and title of the officer)
, personally appeared ,
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and
acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on
the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF
PERJURY under the laws of the State of California that the foregoing paragraph is true and correct
WITNESS my hand and official seal.
(SEAL)
_
SIGNATURE OF NOTARY PUBLIC
Page 3 of 3
VS 111 (01/18)
CALIFORNIA COUNTY RECORDERS
Alameda………………… 1106 Madison Street, First Floor, Oakland, CA 94607, (510) 272-6362
Alpine…………………... 99 Water Street, or P.O. Box 155, Markleeville, CA 96120, (530) 694-2283
Amador…………………. 810 Court Street, Jackson, CA 95642, (209) 223-6468
Butte……………………. 25 County Center Drive, Suite 105, Oroville, CA 95965, (530) 538-7691
Calaveras……………….. 891 Mountain Ranch Road, San Andreas, CA 95249, (209) 754-6372
Colusa…………………... 546 Jay Street, Suite 200, Colusa, CA 95932, (530) 458-0500
Contra Costa……………. 555 Escobar Street, or P.O. Box 350, Martinez, CA 94553, (925) 335-7910
Del Norte……………….. 981 H Street, Suite 160, Crescent City, CA 95531, (707) 464-7216
El Dorado………………. 360 Fair Lane, Placerville, CA 95667, (530) 621-5490
Fresno…………………... 2281 Tulare Street, Room 302, or P.O. Box 766, Fresno, CA 93712, (559) 600-3476
Glenn…………………… 516 West Sycamore Street, Second Floor, Willows, CA 95988, (530) 934-6412
Humboldt………………. 825 Fifth Street, Fifth Floor, Eureka, CA 95501, (707) 445-7382
Imperial………………… 940 West Main Street, Suite 202, El Centro, CA 92243, (760) 482-4272
Inyo…………………….. 168 North Edwards Street, or P.O. Drawer F, Independence, CA 93526, (760) 878-0222
Kern……………………. 1655 Chester Avenue, Bakersfield, CA 93301, (661) 868-6400
Kings…………………… Government Center, 1400 West Lacey Boulevard, Hanford, CA 93230, (559) 582-3211, ext. 2470
Lake……………………. Courthouse, 255 North Forbes Street, Lakeport, CA 95453, (707) 263-2293
Lassen………………….. 220 South Lassen Street, Suite 5, Susanville, CA 96130, (530) 251-8234
Los Angeles……………. 12400 Imperial Highway, Norwalk, CA 90650, (800) 201-8999 or (562) 462-2137
Madera…………………. 200 West Fourth Street, Madera, CA 93637, (559) 675-7724
Marin…………………… 3501 Civic Center Drive, Suite 232, San Rafael, CA 94903, (415) 473-6094
Mariposa……………….. 4982 Tenth Street, or P.O. Box 35, Mariposa, CA 95338, (209) 966-5719
Mendocino……………... 501 Low Gap Road, Room 1020, Ukiah, CA 95482, (707) 234-6822
Merced…………………. 2222 M Street, Merced, CA 95340, (209) 385-7627
Modoc………………….. 108 E. Modoc Street, Alturas, CA 96101, (530) 233-6205
Mono…………………… 74 School Street, Annex 1, or P.O. Box 237, Bridgeport, CA 93517, (760) 932-5530
Monterey……………….. 168 West Alisal Street, First Floor, or P.O. Box 29, Salinas, CA 93902-0570, (831) 755-5041
Napa……………………. 900 Coombs Street, Room 116, or P.O. Box 298, Napa, CA 94559-0298, (707) 253-4105
Nevada…………………. 950 Maidu Avenue, Suite 210, Nevada City, CA 95959, (530) 265-1221
Orange…………………. 12 Civic Center Plaza, Room 101, Santa Ana, CA 92701, (714) 834-2500
Placer…………………... 2954 Richardson Drive, Auburn, CA 95603, (530) 886-5600
Plumas…………………. 520 Main Street, Room 102, Quincy, CA 95971, (530) 283-6218 or (530) 283-6256
Riverside………………. 2724 Gateway Drive, or P.O. Box 751, Riverside, CA 92502-0751, (951) 955-6200
Sacramento…………….. 600 Eighth Street, or P.O. Box 839, Sacramento, CA 95812-0839, (916) 874-6334
San Benito……………… County Courthouse, 440 Fifth Street, Room 206, Hollister, CA 95023, (831) 636-4046
San Bernardino………… 222 West Hospitality Lane, First Floor, San Bernardino, CA 92415-0022, (855) 732-2575
San Diego……………… 1600 Pacific Highway, Suite 260, San Diego, CA 92101, (619) 237-0502
San Francisco………….. One Dr. Carlton B. Goodlett Place, City Hall, Room 190, San Francisco, CA 94102, (415) 554-5596*
San Francisco Health Dept. 101 Grove Street, Room 105, San Francisco, CA 94102, (415) 554-2700**
San Joaquin……………. 44 North San Joaquin Street, Suite 260, or P.O. Box 1968, Stockton, CA 95201, (209) 468-3939
San Luis Obispo……….. 1055 Monterey Street, Room D120, San Luis Obispo, CA 93408, (805) 781-5080
San Mateo……………… 555 County Center, First Floor, Redwood City, CA 94063-1665, (650) 363-4500
Santa Barbara………….. 1100 Anacapa Street, or P.O. Box 159, Santa Barbara, CA 93102-0159, (805) 568-2250
Santa Clara…………….. 70 West Hedding Street, San Jose, CA 95110, (408) 299-5688
Santa Cruz……………... 701 Ocean Street, Room 230, Santa Cruz, CA 95060, (831) 454-2800
Shasta…………………... 1450 Court Street, Suite 208, Redding, CA 96001-1670, (530) 225-5678
Sierra…………………… 100 Courthouse Square, Room 11, or P.O. Drawer D, Downieville, CA 95936, (530) 289-3295
Siskiyou……………….. 311 Fourth Street, Room 107, Yreka, CA 96097, (530) 842-8065
Solano…………………. 675 Texas Street, Suite 2700, Fairfield, CA 94533-6338, (707) 784-6294
Sonoma………………… 585 Fiscal Dive, Room 103-F, or P.O. Box 1709, Santa Rosa, CA 95402, (707) 565-2651
Stanislaus……………… 1021 I Street, Suite 101, Modesto, CA 95354-0847, (209) 525-5250
Sutter………………….. 433 Second Street, Yuba City, CA 95991, (530) 822-7134
Tehama………………… 633 Washington Street, Room 11, or P.O. Box 250, Red Bluff, CA 96080, (530) 527-3350
Trinity…………………. 11 Court Street, or P.O. Box 1215, Weaverville, CA 96093, (530) 623-1215
Tulare………………….. County Civic Center, 221 South Mooney Boulevard, Room 103, Visalia, CA 93291, (559) 636-5050
Tuolumne……………… 2 South Green Street, Third Floor, Sonora, CA 95370, (209) 533-5531
Ventura………………… 800 South Victoria Avenue, Ventura, CA 93009-1260, (805) 654-3665
Yolo…………………… 625 Court Street, Room B01, or P.O. Box 1130, Woodland, CA 95776-1130, (530) 666-8130
Yuba…………………… 915 Eighth Street, Suite 107, Marysville, CA 95901, (530) 749-7850
* Public Marriages
** Birth and Death Certificates
Rev 05/15/15
POWER OF ATTORNEY TO PROVIDE CARE FOR CHILD
I, __________________________, being of sound mind and body, declare the following:
1. I am the natural mother/father of ____________________who was born on _______________.
2. I am presently incarcerated at _____________________located in
________________________.
3. During this time, my child ________________, is being cared for by ____________________.
4. I wish to give full Power of Attorney to with
respect to the care and custody of my child .
5. Specifically, I give ____________________ full Power of Attorney with respect to the care and
custody of _____________ in matters affecting his/her medical needs, schooling, legal matters,
public assistance, Medi-Cal, CalWORKS, and all other matters pertaining to his/her well-being.
6. I understand that this Power of Attorney is not a legal custody order and that I am not giving up
my parental rights by signing this document.
7. This Power of Attorney will remain in effect until ______________or until revoked in writing.
Signed this ______ day of ______________________(month), ________ (year).
______________________________________
Signature of parent
State of California
County of _________________________________
On this day of , in the year before me, ___________________
[name and title of officer], personally appeared _______________________________ [name of
signer], who proved to me on the basis of satisfactory evidence to be the person whose name is
subscribed to the within instrument and acknowledged to me that s/he executed the same in his/her
authorized capacity, and that by his/her signature on the instrument, the person, or the entity upon
behalf which the person acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws of the State of California that the
foregoing paragraph is true and correct.
WITNESS my hand and official seal.
[Notary Public Signature]
POWER OF ATTORNEY TO PROVIDE CARE FOR CHILD
I, __________________________, being of sound mind and body, declare the following:
1. I am the natural mother/father of ________________________who was born on _______________.
2. I am presently incarcerated at _____________________located in____
________________________.
3. During this time, my child _____________________ is being cared for by ____________________.
4. I wish to give Power of Attorney to with respect to the
care and custody of my child .
5. Specifically, I give ____________________ full Power of Attorney with respect to the care and custody of
_____________ in matters affecting his/her medical needs, schooling, legal matters, public assistance, Medi-
Cal, CalWORKS, and all other matters pertaining to his/her well-being.
6. I understand that this Power of Attorney is not a legal custody order and that I am not giving up my parental
rights by signing this document.
7. This Power of Attorney will remain in effect until _______________________ or until revoked in writing.
Signed this ______ day of _____________________ (month), ________ (year).
______________________________________
Signature of Parent
STATEMENT OF WITNESSES
On the date written above, I declare under penalty of perjury under the laws of California that the person who
signed or acknowledged this document is personally known to me (or proved to me on the basis of convincing
evidence) to be the principal, that the principal signed or acknowledged this power of attorney in my presence,
that the principal appears of sound mind and under no duress, fraud, or undue influence, that I am over the age
of eighteen, and that I am not the person appointed as attorney in fact (agent) by this document.
_______________________________________ [Signature of Witness #1]
_______________________________________ [Printed or typed name of Witness #1]
_______________________________________ [Address of Witness #1, Line 1]
_______________________________________ [Address of Witness #1, Line 2]
_______________________________________ [Signature of Witness #2]
_______________________________________ [Printed or typed name of Witness #2]
_______________________________________ [Address of Witness #2, Line 1]
_______________________________________ [Address of Witness #2, Line 2]
[Probate Code sections 4121 and 4122.]
PLEASE HELP IMPLEMENT ANTI-SHACKLING!
Getting a bill signed is only the first step in making a law
become real! LSPC is working to make sure this law is
implemented across the state. You can help us!
Per California Penal Code Section 3407, starting January 1,
2013, no pregnant woman detained in a California prison,
jail or juvenile facility may be handcuffed behind her back,
chained around her ankles or shackled around her belly. That
is the bottom line: once it is known that she is pregnant, none
of these kinds of restraints can be used during her
entire pregnancy!
During a medical emergency, a medical person may
require that a pregnant woman be released from her
restraints.
During labor, delivery and recovery, she is not to be
restrained at all unless there is a stated security reason for
that restraint. However, if a medical person states that the
woman must be released from her restraints, no restraints
may be used.
If you or anyone pregnant woman you know has been
wrongly restrained, please contact us at the address below.
Together, we can make this law a reality!
4400 Market Street
Oakland, CA 94608
Phone: (415) 255-7036
Fax: (415) 552-3150
www.prisonerswithchildren.org
info@prisonerswithchildren.org
OUR MISSION
Legal Services for Prisoners with Children organizes communities impacted by the criminal
justice system and advocates to release incarcerated people, to restore human and civil rights and
to reunify families and communities. We build public awareness of structural racism in policing,
the courts and prison system and we advance racial and gender justice in all our work.
Our strategies include legal support, trainings, advocacy, public education, grassroots
mobilization and developing community partnerships.
Legal Services for Prisoners with Children
4400 Market Street
Oakland, CA 94608
Phone: (415) 255-7036
Fax: (415) 552-3250
www.prisonerswithchildren.org
