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IN THE COURT OF COMMON PLEAS FOR ADAMS COUNTY, PENNSYLVANIA CIVIL ACTION - LAW
| Name | PLAINTIFF |
|---|---|
| vs. | |
| Name | DEFENDANT 1 |
| and (if applicable): | |
| Name | DEFENDANT 2 |
CASE NO. _____
ACTION IN CUSTODY
PARENTING PLAN
This parenting plan involves the following child/children:
| Child's INITIALS | Age | Where does the child live? |
|---|---|---|
| 1. | ||
| 2. | ||
| 3. |
If you have children not addressed by this parenting plan, name here:
| Child's INITIALS | Age | Where does the child live? |
|---|---|---|
| 1. ________ | ______ | ______ |
| 2. ________ | ______ | ______ |
| 3. ________ | ______ | ______ |
Legal Custody (who makes decisions about certain things):
| Check one | |||
| Diet | Both parties decide together | Plaintiff | Defendant |
|---|---|---|---|
| Religion | Both parties decide together | Plaintiff | Defendant |
| Medical Care | Both parties decide together | Plaintiff | Defendant |
| Mental Health Care | Both parties decide together | Plaintiff | Defendant |
| Discipline | Both parties decide together | Plaintiff | Defendant |
| Choice of School | Both parties decide together | Plaintiff | Defendant |
| Choice of Study | Both parties decide together | Plaintiff | Defendant |
| School Activities | Both parties decide together | Plaintiff | Defendant |
| Sports Activities | Both parties decide together | Plaintiff | Defendant |
| Additional Items | Both parties decide together | Plaintiff | Defendant |
| Explain the process you will use to make decisions:(For example, the parent confronted with or anticipating the choice will call the other parent when the choice presents itself, and the other parent must agree or disagree within 24 hours of any deadline.) | |||
Physical Custody (where the child/ren live):
The child/ren’s residence is with:
Describe which days and which times of the day the child/ren will be with each person:
Sunday: _____
Monday: _____
Tuesday: _____
Wednesday: ___
Thursday: ___
Friday: _____
Saturday: ___
Describe where and when the child/ren will be dropped off and/or picked up (day and time of day):
Drop-Off:
Where:_____
When: ___
Pick-Up:
Where: ___
When: _____
If one of you doesn't show up, how long will the other wait? ___
If there are any extraordinary costs (taxi, train, airplane, etc.), who will pay for which costs?
HOLIDAYS – Where will the child/children stay?
| HOLIDAYS – where will the child/children stay? | |||
| HOLIDAY | YEAR A | YEAR B | EVERY YEAR |
|---|---|---|---|
| Martin Luther King Day | |||
| Presidents Day | |||
| Easter | |||
| Memorial Day | |||
| Fourth of July | |||
| Labor Day | |||
| Yom Kippur | |||
| Rosh Hashanah | |||
| Thanksgiving | |||
| Vacation after Thanksgiving | |||
| Christmas Vacation | |||
| Kwanzaa | |||
| New Year’s Eve/Day | |||
| Spring Vacation | |||
| Easter Sunday | |||
Child’s Birthday ___ ___ ___ ___ Mother’s Day ___ ___ ___ ___ Father’s Day ___ ___ ___ ___ Other ___ ___ ___ ___ Other ___ ___ ___ ___ Other ___ ___ ___ ___ Summer Schedule/ Vacation Plans:
The quick brown fox jumps over the lazy dog.
Summer Schedule/ Vacation Plans:
Special Activities or School Activities:
Child’s Initials List Activity Both attend? If not, which parent attends?
Temporary changes to this parenting schedule:
From time to time, one of you might want or need to rearrange the parenting time schedule due to work, family, or other events. You can attempt to agree on these changes. If you cannot agree, the parent receiving the request will make the final decision.
| The parent asking for the change will ask: (check all that apply) | ||||
| in person | by letter/mail | by phone | by email | by co-parenting app |
|---|---|---|---|---|
| No later than: | 12 hours | 24 hours | 1 week | 1 month ahead of time. |
| The parent being asked for a change will reply: (check all that apply) | ||||
| in person | by letter/mail | by phone | by email | by co-parenting app |
| No later than | 12 hours | 24 hours | 1 week | 1 month after being asked |
Generally, by what method may parents contact one another?
When the child/ren is/are with one of you, how may they contact the other parent?
When and how may you contact the child when the child is with the other parent?
In the event that proposed changes, disputes or alleged breaches of this parenting plan and custody order are necessary or desired, the parties agree that such changes will be addressed by the following method (specify method, i.e., informal discussion, mediation, court action, etc.)
Other (Anything else you want to agree on):
| Date | Signature of Mother |
|---|---|
| Date | Signature of Father |
| Date | Signature of Mother’s Witness |
| Date | Signature of Father’s Witness |