Valley State Prison Inmate Family Council 


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There is a new form for consent for minors.  Please make yourself familiar with the form if you have minors.  
I, __________________________________ give permission for:                         (Parent/Legal Guardian)
NAME: ______________________________ AGE: ________ DOB: _______________
NAME: ______________________________ AGE: ________ DOB: _______________
NAME: ______________________________ AGE: ________ DOB: _______________
NAME: ______________________________ AGE: ________ DOB: _______________
To visit _____________________________________ at a California State Prison or Institution (Inmate Name and CDCR Number)
With ________________________________ for one year. I understand this Authorization is to be updated        (Name of Accompanying Adult)
annually and that the minor Birth Certificate, or a Certified copy of the Birth Certificate, from the County Recorders Office is required. Satisfactory Evidence of Proof of legal guardianship to said minor(s) is required as an attachment to this authorization form.
I understand that this authorization can only be revoked IN WRITING, and will remain in effect for one (1) year, or until written notice of revocations is issued by the California Department of Corrections and Rehabilitation.
_________________________________      ___________________   (Signature of Parent/Legal Guardian)        (Date)
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.
                                                             CERTIFICATE OF ACKNOWLEDGEMENT
State of California County of _________________________________
On _______________________ before me, ______________________________________ personally appeared                  (DATE)     (Name and Title of the Officer)
___________________________________________ who proved to me on the basis of satisfactory evidence to               (Name Parent/Legal Guardian)
be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledge 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.
Signature ___________________________________ (SEAL)