Fillable Custodial Guardianship Agreement and Family Plan (Vermont Judiciary)

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Custodial Guardianship Agreement and Family Plan (Vermont Judiciary)

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Form PMG61 – Custodial Guardianship Agreement and Family Plan (8/2014) Page 1 of 3
STATE OF VERMONT
SUPERIOR COURT
PROBATE DIVISION
Unit
Docket No.
In re Guardianship of :
Custodial Guardianship Agreement and Family Plan
This Family Plan is for the following child(ren) of the parents:
Name of Child
DOB
Name of Child
DOB
Name of Child
DOB
Name of Child
DOB
Name of Child
DOB
Name of Child
DOB
Name of Child
DOB
This Family Plan is agreed upon by the following parties:
☐ Guardian/Proposed Guardian: _______________________________________________
☐ Parent: __________________________________________________________________
I am a: (check one) ☐ custodial parent ☐ non-custodial parent
☐ Parent: __________________________________________________________________
I am a: (check one) ☐ custodial parent ☐ non-custodial parent
We hereby agree that the Probate Division may issue an Order establishing a custodial minor guardianship
for the minor child(ren) with ____________________________________________ as guardian under the
following terms and conditions:
1. As the guardian of the child(ren), I, ______________________________________ agree that I will:
a) Take custody of the child(ren) and establish the child(ren)’s place of residence provided that I
shall not establish a residence for the child outside of the State of Vermont unless authorized by
the Court following notice to the parties and an opportunity for hearing.
b) Make decisions related to the child’s education;
c) Make decisions related to the child’s physical and mental health including consent to medical
treatment and medication;
d) Make the child(ren) available for parent child contact as ordered by the Court. If the children
are unavailable due to illness or other emergency, I agree that I will work with the parent to
schedule make-up contact.
e) Make decisions concerning the child(ren)’s contact with persons other than the parents
including reasonable contact with any siblings of the child(ren);
Name of guardian
Form PMG61 – Custodial Guardianship Agreement and Family Plan (8/2014) Page 2 of 3
f) File an annual status report with the Probate Division and provide a copy of the report to each
parent.
g) Consult with _________________________________________prior to making decisions
related to:
i.Changes in the child(ren)’s school;
ii.Changes in the child(ren)’s doctors or other medical providers;
iii.Other: _____________________________________________________________________
_____________________________________________________________________
h) Provide the parent(s) named above with notice and the opportunity to participate in:
i. Non-emergency medical appointments for the child(ren);
ii. Meetings with the child(ren)’s teachers or other school personnel;
iii. Other: ___________________________________________________________________
_____________________________________________________________________
2. As a parent of the child, I, ______________________________________________agree that I will:
a) Make myself available for parent child contact as ordered by the Court. If due to an
emergency, I am unable to have contact with the child, I will notify the Guardian as soon as
possible.
b) Keep the Guardian and the Court informed of any changes in my address or phone number.
c) Other: _______________________________________________________________________
_______________________________________________________________________
If only one parent is signing this agreement, skip to Question 4 and leave Question 3 blank. If
two parents are signing the agreement, the other parent’s name should be named in paragraph
3.
3. As a parent of the child, I, ______________________________________________agree that I will:
a) Make myself available for parent child contact as ordered by the Court. If due to an
emergency, I am unable to have contact with the child, I will notify the Guardian as soon as
possible.
b) Keep the Guardian and the Court informed of any changes in my address or phone number.
c) Other: _______________________________________________________________________
_______________________________________________________________________
4. Estimated Duration of Guardianship if Known: We agree that the guardianship established by the
Court should remain in place until the following event or events take place: (This section is
optional)
We understand that the guardianship cannot end before the child’s 18
th
birthday without an
order from the Probate Court terminating the guardianship.
5. Parent Child Contact Schedule:
We agree that the Court may order contact between the parent(s) named above and the minor
child(ren) as follows:
a) Weekday and/or weekend contact during the school year:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Name of parent or parents
Name of 1
st
parent
Name of 2nd
t
parent
Form PMG61 – Custodial Guardianship Agreement and Family Plan (8/2014) Page 3 of 3
b) Holiday contact:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
c) Contact during school vacations:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
6. Parent Child Contact for Non-Custodial parent (to be filled out only if there is an order establishing parent child
contact for one of the parents).
The parent child contact schedule for __________________________________ shall be as set forth
in the attached Order from the ☐ Family Division of the Vermont Superior Court or
☐Out of State Court .
We, the undersigned, agree that the provisions of this parenting plan may be incorporated into the
parental rights and responsibilities order of this court:
Parent’s Printed Name
Parent’s Signature
Date
Parent’s Printed Name
Parent’s Signature
Date
Proposed Guardian’s Printed Name
Proposed Guardian’s Signature
Date
Name of parent
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Custodial Guardianship Agreement and Family Plan (Vermont Judiciary)

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Completed 30 July 2020

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