ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address):

FOR COURT USE ONLY

JV-419A

FAX NO. (Optional):

SUPERIOR COURT OF CALIFORNIA, COUNTY OF

                 TELEPHONE NO.:

E-MAIL ADDRESS (Optional):

ATTORNEY FOR (Name):

STREET ADDRESS:

MAILING ADDRESS:

CITY AND ZIP CODE:

BRANCH NAME:

CHILD'S NAME:

GUARDIANSHIP (JUVENILE)—CHILD'S CONSENT AND WAIVER OF RIGHTS

CASE NUMBER:

To the child: Review this form with your attorney. The judge will ask you if you understand your rights to family maintenance and 
reunification services, your right to a trial, and, if applicable, your rights under the Indian Child Welfare Act and whether you are 
voluntarily giving up those rights and consenting to the guardianship.

1.  

I am the child in this court case. I understand that I have the right to receive family maintenance services to help me stay 
with my family and family reunification services to help me return to my family.

For items 2 through 8, initial the box for each item that applies. If you have a question about an item, ask your attorney or the judge 
before you initial that item.                                                                                                                                                               Initial

2.  The types of services that may be available have been explained to me. 

3.  I am not interested in receiving family maintenance services or family reunification services. 

4.  I believe that a guardianship with (name):
     is in my best interest, and I consent to his or her appointment as the guardian of my

 person    

 estate.       

5.  I understand that by signing this document, I give up the following rights:

a.  The right to trial or hearing on my placement
b.  The right to see and hear witnesses who testify
c.  The right to cross-examine witnesses, including the people who wrote any reports and the people who 
     provided information that is in the report 
d.  The right to testify on my own behalf and to present my own evidence and witnesses 
e.  The right to use the court's authority to compel witnesses to come to court and produce evidence 
f.   The right to assert any privilege against self-incrimination in this proceeding 
g.  The right to receive family maintenance services and family reunification services 

6.  

  Waiver of rights under the Indian Child Welfare Act (ICWA) (25 U.S.C. § 1901 et seq.)

a.  I am an Indian child.

b.    

  By signing this document, I understand that I have the following ICWA rights, which I am giving up:          Initial

(1)  The right to request a transfer of the proceedings to the jurisdiction of my tribe 

(2)

(3)

The right to require a showing that active efforts were made to provide remedial services and 
rehabilitative programs designed to prevent the breakup of my Indian family and that these efforts 
have proven unsuccessful 

The right to require clear and convincing proof, including the testimony of qualified expert witnesses, 
that my continued custody with my parent or my Indian custodian is likely to result in serious 
emotional or physical damage to me 

(4)  The right to be placed according to the statutory preference 

Form Approved for Optional Use 
Judicial Council of California 
JV-419A [Rev. January 1, 2007]

GUARDIANSHIP (JUVENILE)—
CHILD'S CONSENT AND WAIVER OF RIGHTS

Page 1 of 2

Welfare and Institutions Code, § 360(a);
Cal. Rules of Court, rules 5.664, 5.695
www.courtinfo.ca.gov

CHILD'S NAME:

CASE NUMBER:

JV-419A

7.    

This waiver of rights and consent to guardianship is given with the understanding that the individual named in 
item 4 will be appointed as my guardian. If that individual is not appointed or his or her status as my guardian is 
terminated, this waiver and consent is withdrawn and the right to a trial on the issue of my placement, my right to child 
welfare services, and any rights I may have under ICWA will be reinstated as they existed on the date this form was 
signed.  

8.   I have discussed my rights with my attorney, and I knowingly and intelligently waive those rights. 

(TYPE OR PRINT NAME)

(SIGNATURE)

9.   The child is unable to read or understand this form because his or her primary language is (specify):

DECLARATION OF INTERPRETER

10.

I declare under penalty of perjury and under the laws of the State of California that I have, to the best of my ability, read or 
translated this form for the child who said he or she understood the form before signing it.

(TYPE OR PRINT NAME)

(SIGNATURE OF INTERPRETER)

11.  I am the attorney for the child and I have explained to him or her the following:

DECLARATION OF ATTORNEY (REQUIRED)

  The rights under the Indian Child Welfare Act;

•  
•    The nature of family maintenance services and family reunification services;
•

•
•

The right to a trial, the right to assert the privilege against self-incrimination, the right to confront and cross-examine 
witnesses, the right to subpoena witnesses, and the right to present evidence on one's own behalf;
The nature of a guardianship and his or her continuing rights and responsibilities if a guardian is appointed; and
That his or her waiver of rights and consent to guardianship will result in the appointment of the person named in item 
4 as his or her guardian. If that individual is not appointed or his or her status as the child's guardian is terminated, this 
waiver and consent will be withdrawn and the right to a trial on the issue of the child's placement, the right to receive 
family maintenance and reunification services, and any rights he or she may have under ICWA will be reinstated.

12.  

I am satisfied the child understands and voluntarily waives those rights and consents to the establishment of the guardianship.

Date:

Date:

Date:

(TYPE OR PRINT NAME)

(SIGNATURE OF ATTORNEY)

JV-419A [Rev. January 1, 2007]

Page 2 of 2

GUARDIANSHIP (JUVENILE)—
CHILD'S CONSENT AND WAIVER OF RIGHTS