Emergency Child Custody Agreement Form
Child Information
Full Name of Child
Date of Birth
Age
Current Address
Parent / Legal Guardian Information
Full Name
Phone Number
Address
Other Parent/Guardian Full Name
Phone Number
Address
Emergency Custody Details
Reason for Emergency Custody
Requested By
Effective Date
Expiration Date (if applicable)
Special Instructions
Signatures
Parent/Guardian Signature
Date
Other Parent/Guardian Signature
Date
Witness/Notary Signature
Date