Form 104 "Application for Care by Law Enforcement Officer" - Kansas

What Is Form 104?

This is a legal form that was released by the Kansas Judicial Branch - a government authority operating within Kansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2013;
  • The latest edition provided by the Kansas Judicial Branch;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 104 by clicking the link below or browse more documents and templates provided by the Kansas Judicial Branch.

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Download Form 104 "Application for Care by Law Enforcement Officer" - Kansas

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5/1/13
104
APPLICATION FOR CARE BY
LAW ENFORCEMENT OFFICER
Pursuant to K.S.A. 38-2232(c)
I, ________________________________________, a law enforcement officer for the
___________________________________, apply for shelter for the following described child in
the protective custody of law enforcement for the reasons set forth below:
1.
Name of Child: ________________________________________ Year of Birth: ______
Address:
________________________________________
male or female
________________________________________
Child’s Parent, Parents or Nearest Relative:
2.
Name:
_________________________________________
Address:
_________________________________________
Phone:
_________________________________________
3.
Person(s) With Whom The Child Has Been Residing:
Name:
_________________________________________
Address:
_________________________________________
Phone:
_________________________________________
4.
I, the undersigned applicant, believe that each child named above is a Child in Need of
Care and that there are reasonable grounds to believe that the circumstances or condition of
the child is such that, unless placed in the immediate custody of the shelter facility or other
responsible person, the child would be harmed.
The specific facts on which I base this belief are as follows:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Further, I understand that it is my statutory duty pursuant to K.S.A. 38-2232(a) to provide
the County/District Attorney, without unnecessary delay, all the information in my
possession pertaining to each child, each child’s parents or other persons interested in or
likely to be interested in the child, and all other facts and circumstances which caused the
child to be taken into custody.
_____ Juvenile Intake and Assessment should contact me prior to placement decision.
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5/1/13
104
APPLICATION FOR CARE BY
LAW ENFORCEMENT OFFICER
Pursuant to K.S.A. 38-2232(c)
I, ________________________________________, a law enforcement officer for the
___________________________________, apply for shelter for the following described child in
the protective custody of law enforcement for the reasons set forth below:
1.
Name of Child: ________________________________________ Year of Birth: ______
Address:
________________________________________
male or female
________________________________________
Child’s Parent, Parents or Nearest Relative:
2.
Name:
_________________________________________
Address:
_________________________________________
Phone:
_________________________________________
3.
Person(s) With Whom The Child Has Been Residing:
Name:
_________________________________________
Address:
_________________________________________
Phone:
_________________________________________
4.
I, the undersigned applicant, believe that each child named above is a Child in Need of
Care and that there are reasonable grounds to believe that the circumstances or condition of
the child is such that, unless placed in the immediate custody of the shelter facility or other
responsible person, the child would be harmed.
The specific facts on which I base this belief are as follows:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Further, I understand that it is my statutory duty pursuant to K.S.A. 38-2232(a) to provide
the County/District Attorney, without unnecessary delay, all the information in my
possession pertaining to each child, each child’s parents or other persons interested in or
likely to be interested in the child, and all other facts and circumstances which caused the
child to be taken into custody.
_____ Juvenile Intake and Assessment should contact me prior to placement decision.
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5/1/13
_____ Juvenile Intake and Assessment has my permission to make a placement decision
after reviewing all options.
_____ Not applicable
5.
Pursuant to K.S.A. 38-2217(a)(3),
Identity of Individual Receiving Custody
may give consent to the following:
a.
Dental treatment by a licensed dentist;
b.
Diagnostic examinations including but not limited to withdrawal of blood and other
bodily fluids, x-rays and other laboratory examinations;
c.
Releases and inspections of medical history records;
d.
Immunizations;
e.
Administration of lawfully prescribed drugs; and
f.
Examinations including, but not limited to, the withdrawal of blood or other body
fluids or tissues for the purpose of determining the child’s parentage.
Health care providers rendering care or treatment are advised that pursuant to K.S.A.
38-2217(a)(5), “Any health care provider who in good faith renders hospital, medical,
surgical, mental or dental care or treatment to any child or discloses protected health
information authorized by this section shall not be liable in any civil or criminal action for
failure to obtain consent of a parent.”
NOTICE TO PERSON(S) RECEIVING CUSTODY:
K.S.A. 38-2232(d) requires that the person receiving custody of the child forward a copy of this
application to the County/District Attorney without unnecessary delay.
K.S.A. 38-2232(e) requires, absent a court order to the contrary, the child must be released after 72
hours, excluding Saturdays, Sundays and holidays.
___________________________________
____________________
____________
Applicant Officer’s Signature
Date
Time
Name
Address
Telephone Number
[Fax Number]
[E-mail Address]
Pursuant to K.S.A. 38-2232(f), absent a court order to the contrary, the County/District Attorney or
the placing law enforcement agency has the authority to direct the release of the child at any time.
Child delivered to: ______________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
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5/1/13
Authority
K.S.A. 38-2232.
Notes on Use
Whenever a law enforcement officer takes a child into custody without a court order and
places the child as authorized by K.S.A. 38-2232(a), the law enforcement officer shall complete an
application for care. The facility or person to whom the child is delivered shall have physical
custody and provide care and supervision for the child upon receipt of the officer’s application.
The person or facility receiving the child shall furnish a copy of the application to the
county/district attorney without unnecessary delay. The law enforcement officer is required to
provide to the county/district attorney all information available pertaining to the child, the parents
or other persons interested in or likely to be interested in the child, and other information relating
to the decision to take the child into custody.
The placement which a law enforcement officer designates for a child pursuant to K.S.A.
38-2232 shall discharge the child not later than 72 hours following admission, excluding
Saturdays, Sundays and legal holidays, unless a court has entered an order pertaining to temporary
custody or release.
K.S.A. 38-2232(a) provides that a child who is alleged, but not yet adjudicated, to be a
child in need of care pursuant to K.S.A. 38-2202(d)(9) or (d)(10), the runaway provisions, may be
delivered to a juvenile detention facility or other secure facility if, after delivery of the child to a
shelter facility, the person in charge of the facility at that time and the law enforcement officer
determine that the child will not remain in the shelter facility. The child may not be detained in a
juvenile detention facility or other secure facility for more than 24 hours, excluding Saturdays,
Sundays and legal holidays. The statute does not otherwise contemplate placement of a child in a
juvenile detention facility or other secure facility, except for violation of a valid court order, as
provided in K.S.A. 38-2260, Forms 172, 173 and 174.
In the absence of a court order to the contrary, the county/district attorney or the placing
law enforcement agency shall have the authority to direct the release of the child at any time.
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