Application for Membership in the Davidson County Juvenile Court Appointment Panel ApplicantFirst Name:*Last Name:*Email Address:* Experience1. I am applying for inclusion in the Davidson County Juvenile Court appointment list for: Delinquency Dependent/Neglect Truancy/Educational Neglect 2. I was admitted to practice law in the state of Tennessee on the following date and am an active member of the Tennessee Bar in good standing. Date Format: MM slash DD slash YYYY 3. My Board of Professional Responsibility Number is:4. I have been engaged in the active practice of law since: Date Format: MM slash DD slash YYYY 5. Have you ever been disciplined by the bar of any state, by the Tennessee Disciplinary Board, or by any court in this state or any other state? If so, please list the date of the action and an explanation of the sanction and circumstances.6. I read/write/speak the following languages:7. During the five years preceding this application, have you been arrested, summoned, charged, or convicted of any criminal offenses? If so, please list the date and nature of the offense and an explanation of the disposition and circumstances.8. If you are experienced in Juvenile Court practice, are you willing to serve as a mentor for a new or less-experienced attorney?YesNo9. Do you wish to volunteer to serve on a panel of attorneys who are willing to represent at a reduced or sliding scale fee to those parents who are above the indigency level but who cannot afford a full fee?YesNoRepresentationFor each category of representation that you are willing to accept please indicate the amount of experience.Representation of Parent Respondents in Abuse/Neglect:Representation of Children in Abuse/NeglectGuardian Ad LitemRepresentation of Parent Respondents for Contempt MattersRepresentation of Children in Delinquency MattersRepresentation of Children in Truancy/Unruly Matters11. What types of CLE or specific training have you attended that focused on Juvenile Court proceedings in the past 12 months?12. Are you willing to participate in any extra training that is provided by either the Juvenile Court or the Bar Committee?YesNoAUTHORIZATION FOR RELEASE OF INFORMATION: I hereby authorize all educational institutions, government agencies and instrumentalities (including bar associations and bar examiners of other jurisdiction), employers, and business and professional associates (past or present), to release to the Davidson County Juvenile Court, Nashville, Tennessee any non-privileged information, files, or records requested by them for the purpose of processing this application.* Accept AFFIRMATION OF TRUTHFUL STATEMENTS: I further state that I have carefully read the foregoing application and certify that the information therein is true to the best of my knowledge and belief. I fully understand that failure to make truthful disclosure of any fact or item of information required may result in the denial of my application and such other action as the court deems appropriate.* Accept *The Davidson County Juvenile Court adds "gender identity and sexual orientation" to all references to "race, religion, national origin or gender" in the Creed of Professionalism. I hereby acknowledge that I have read the Lawyer’s Creed of Professionalism, and that I understand its significance to the practice of law, and that I will at all times abide by this creed.* Accept View the Lawyer's Creed of ProfessionalismContact InformationBusiness Address:Home Address:Office Phone:Home Phone:Cell Phone:PhoneThis field is for validation purposes and should be left unchanged.