J4KT Child Custody Order Summary

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

MonthDayYear
Date
Date Order Received by Preschool

MonthDayYear
Date
Received by (Name & Position)
Parent / Guardian Providing Order
Other Parent / Guardian Providing Order
Summary Prepared By (Name & Position)
Type of Custody*

Shared / JointSole / Exclusive
Primary Physical / Residential Custodian's Address*