~HSCFDC Documentation/Monitoring System~ Title of Form:
Custody Issues
Related Policy:
Filled Out By:
To ensure a partnership with both parents/guardian to share and have input into their child’s education as a partnership with all involved on the child’s behalf. 1304.40 Family Partnerships Procedures Custodian Parent
Timeline:
Orientation or throughout the year –August-May
Specific Directions:
Submitted To:
1) Complete at Parent Orientation 2) Copies of the court order and the yellow copy of custody issues form will be placed in the child’s file. 3) White copy of the custody issues form and a copy of the court order will be submitted to the CFSM upon completion of orientation and place in the CFSM file CFAM
Timeline:
Parent Orientation
Filed In: Note: For duplicate or triplicate forms, please note where each copy of the form is filed.
CFSM file Child’s File – Teacher office
Program Area:
Revised 8/2011
Head Start Child & Family Development Centers, Inc. Center _________________________________ Child’s Name __________________________________ Date ___________________________________ Family Name __________________________________
Custody Issues Form Note: To be filled out only if the parent/ guardian who completed the application has indicated a custody, physical placement, and/ or visitation concern. This form is part of the enrollment procedure. This form will be completed during the orientation. _____1. Parents of Head Start child are legally separated or divorced and not living together. _____2. Parents of the Head Start child were never married. _____3. Paternity of the Head Start child has not been established. _____4. Name of parent(s) who has legal custody of the Head Start child. __________________________________, ___________________________________________ _____5. Name of parent(s) who has physical placement of the Head Start child. _________________________________, ____________________________________________ _____6. Are there custody, physical placement or visitation issues we need to be aware of? _____ Yes
_____ No
_____7. If one of the above issues applies to your family’s situation, you need to provide Head Start with a copy of any court orders pertaining to the custody, periods of physical placement and/ or visitation arrangements. Copies of the order must be in the child’s file and Administrative Office File. Teachers: Please complete below ______ copies received)
_______ (date)
We thank you for taking the time to fill out this form for the safety and well-being of your child. White Copy – CFSM
Yellow Copy – Teacher File
Revised 6/ 2011
