J4TH Child Custody Order Summary

CHILD CUSTODY ORDER SUMMARY
Child's Name
Date of Custody Order

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Date Order Received by Preschool

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Received by (Name & Position)
Parent / Guardian Providing Order
Other Parent / Guardian Providing Order
Summary Prepared By (Name & Position)
Type of Custody
Primary Physical / Residential Custodian's Address

CHILD CUSTODY ORDER SUMMARY