Supervised Visitation – Custodial Only

Fields marked with an * are required.

Children's Information:

First Name *

Last Name *

Birth Date *

Physical Descriptions

Sex *

Male
Femal

Race *

Height *

Weight *

Eye Color *

Hair Color *

Other Identifiable Characteristics?

Other Names Used By Child?

Health Considerations?

Restraining Order Specifications?

Other Pertinent Information

Photograph/Fingerprints Of Child/Copy Of Birth Certificate Mailed?

Child(ren)'s Attorney

Phone

Child(ren)'s Therapist

Phone

Second Child Information:

First Name

Last Name

Birth Date

Physical Description

Sex

Male
Female

Height

Weight

Eye Color

Hair Color

Other Identifiable Characteristics?

Other Names Used By Child?

Health Considerations?

Restraining Order Specifications?

Other Pertinent Information?

Photograph/Fingerprints Of Child/Copy Of Birth Certificate Mailed?

Child(ren)'s Attorney

Phone

Child(ren)'s Therapist

Phone

First Name

Date

First Name

Date

First Name

Date

Authorization is hereby given to Family Services Center by

(Name of custodial parent/legal guardian) *

to obtain emergency medical care for the above child(ren).

Name of Primary Medical Caregiver for the child(ren) *

Medical Caregiver Address *

Medical Caregiver Phone *

Medical Insurance Company *

Policy Number *

E-Signature *

Date

Comment