This document is to be used only as a checklist memorandum of the parents’ preferred options regarding a parenting plan. It is not a legal document and should not be signed by the parties as a binding agreement. It is not effective until an agreed parenting plan is entered with court approval incorporating its terms. The parties are advised that they should have the terms reviewed by a lawyer before they execute an agreed parenting plan.

¨

defined as ____ ¨ a.m. ¨ p.m. to ____ ¨ a.m. ¨ p.m. on Halloween day.

¨

defined as       

¨

¨   [Name of party A] ¨ [Name of party B] shall have Halloween every year.

¨

¨   [Name of party A] ¨ [Name of party B] shall have Halloween in even-numbered years and

¨   [Name of party A] ¨ [Name of party B] shall have Halloween in odd-numbered years.

¨

defined as the Friday before the last Monday in May at ____ ¨ a.m. ¨ p.m. to the fol­lowing Monday ____ at ¨ a.m. ¨ p.m.

¨

defined as       

¨

¨ [Name of party A] ¨ [Name of party B] shall have Memorial Day weekend every year.

¨

¨ [Name of party A] ¨ [Name of party B] shall have Memorial Day weekend in even-numbered years and

¨ [Name of party A] ¨ [Name of party B] shall have Memorial Day weekend in odd-
numbered years.

¨

defined as the Friday before the first Monday in September at ____ ¨ a.m. ¨ p.m. to the following Monday ____ at ¨ a.m. ¨ p.m.

¨

defined as       

¨

¨ [Name of party A] ¨ [Name of party B] shall have Labor Day weekend every year.

¨

¨ [Name of party A] ¨ [Name of party B] shall have Labor Day weekend in even-
numbered years and

¨ [Name of party A] ¨ [Name of party B] shall have Labor Day weekend in odd-
numbered years.

¨

defined as ____ ¨ a.m. ¨ p.m. on December 24 to ____ ¨ a.m. ¨ p.m. on December [24/25].

¨

defined as       

¨

¨ [Name of party A] ¨ [Name of party B] shall have Christmas Eve every year.

¨

¨ [Name of party A] ¨ [Name of party B] shall have Christmas Eve in even-numbered years and

¨ [Name of party A] ¨ [Name of party B] shall have Christmas Eve in odd-numbered years.

¨

defined as ____ ¨ a.m. ¨ p.m. to ____ ¨ a.m. ¨ p.m. on January 6.

¨

defined as ____ ¨ a.m. ¨ p.m. to ____ ¨ a.m. ¨ p.m. on January 6 if January 6 is a Sun­day or otherwise on the Sunday immediately following January 6.

¨

defined as       

¨

¨ [Name of party A] ¨ [Name of party B] shall have Epiphany every year.

¨

¨ [Name of party A] ¨ [Name of party B] shall have Epiphany in even-numbered years and

¨ [Name of party A] ¨ [Name of party B] shall have Epiphany in odd-numbered years.

¨

defined as ____ ¨ a.m. ¨ p.m. to ____ ¨ a.m. ¨ p.m. on Ash Wednesday.

¨

defined as       

¨

¨ [Name of party A] ¨ [Name of party B] shall have Ash Wednesday every year.

¨

¨ [Name of party A] ¨ [Name of party B] shall have Ash Wednesday in even-numbered years and

¨ [Name of party A] ¨ [Name of party B] shall have Ash Wednesday in odd-numbered years.

¨

defined as ____ ¨ a.m. ¨ p.m. to ____ ¨ a.m. ¨ p.m. on Palm Sunday.

¨

defined as       

¨

¨ [Name of party A] ¨ [Name of party B] shall have Palm Sunday every year.

¨

¨ [Name of party A] ¨ [Name of party B] shall have Palm Sunday in even-numbered years and

¨ [Name of party A] ¨ [Name of party B] shall have Palm Sunday in odd-numbered years.

¨

defined as ____ ¨ a.m. ¨ p.m. on [Maundy Thursday/Good Friday/Holy Saturday/Eas­ter Sunday] to ____ ¨ a.m. ¨ p.m. on Easter Sunday.

¨

defined as       

¨

¨ [Name of party A] ¨ [Name of party B] shall have Easter every year.

¨

¨ [Name of party A] ¨ [Name of party B] shall have Easter in even-numbered years and

¨ [Name of party A] ¨ [Name of party B] shall have Easter in odd-numbered years.

¨

defined as ____ ¨ a.m. ¨ p.m. to ____ ¨ a.m. ¨ p.m. on the day of Pentecost.

¨

defined as       

¨

¨ [Name of party A] ¨ [Name of party B] shall have the day of Pentecost every year.

¨

¨ [Name of party A] ¨ [Name of party B] shall have the day of Pentecost in even-
numbered years and

¨ [Name of party A] ¨ [Name of party B] shall have the day of Pentecost in odd-
numbered years.

¨

defined as ____ ¨ a.m. ¨ p.m. to ____ ¨ a.m. ¨ p.m. on November 1.

¨

defined as ____ ¨ a.m. ¨ p.m. to ____ ¨ a.m. ¨ p.m. on November 1 if November 1 is a Sunday or otherwise on the Sunday immediately following November 1.

¨

defined as       

¨

¨ [Name of party A] ¨ [Name of party B] shall have All Saints’ Day every year.

¨

¨ [Name of party A] ¨ [Name of party B] shall have All Saints’ Day in even-numbered years and

¨ [Name of party A] ¨ [Name of party B] shall have All Saints’ Day in odd-numbered years.

¨

defined as ____ ¨ a.m. ¨ p.m. to ____ ¨ a.m. ¨ p.m. on [name of holy day].

¨

defined as ____ ¨ a.m. ¨ p.m. to ____ ¨ a.m. ¨ p.m. on [name of holy day] if that day is a Sunday or otherwise on the Sunday immediately following [name of holy day].

¨

defined as       

¨

¨ [Name of party A] ¨ [Name of party B] shall have [name of holy day] every year.

¨

¨ [Name of party A] ¨ [Name of party B] shall have [name of holy day] in even-
numbered years and

¨ [Name of party A] ¨ [Name of party B] shall have [name of holy day] in odd-numbered years.

¨

defined as beginning at [4:00 p.m./[time]] on the day Rosh Hashanah begins and ending at [9:00 p.m./[time]] the following day.

¨

¨ [Name of party A] ¨ [Name of party B] shall have the first day of Rosh Hashanah every year.

¨

¨ [Name of party A] ¨ [Name of party B] shall have the first day of Rosh Hashanah in even-numbered years and

¨ [Name of party A] ¨ [Name of party B] shall have the first day of Rosh Hashanah in odd-numbered years.

¨

defined as beginning at [9:00 p.m./[time]] on the day the first day of Rosh Hashanah ends and ending at [9:00 p.m./[time]] the following day.

¨

¨ [Name of party A] ¨ [Name of party B] shall have the second day of Rosh Hashanah every year.

¨

¨ [Name of party A] ¨ [Name of party B] shall have the second day of Rosh Hashanah in even-numbered years and

¨ [Name of party A] ¨ [Name of party B] shall have the second day of Rosh Hashanah in odd-numbered years.

¨

defined as beginning at [4:00 p.m./[time]] on the day Yom Kippur begins and ending at [9:00 p.m./[time]] the following day.

¨

¨ [Name of party A] ¨ [Name of party B] shall have Yom Kippur every year.

¨

¨ [Name of party A] ¨ [Name of party B] shall have Yom Kippur in even-numbered years and

¨ [Name of party A] ¨ [Name of party B] shall have Yom Kippur in odd-numbered years.

¨

defined as beginning at [4:00 p.m./[time]] on the day Sukkot begins and ending at [9:00 p.m./[time]] the following day.

¨

¨ [Name of party A] ¨ [Name of party B] shall have the first day of Sukkot every year.

¨

¨ [Name of party A] ¨ [Name of party B] shall have the first day of Sukkot in even-
numbered years and

¨ [Name of party A] ¨ [Name of party B] shall have the first day of Sukkot in odd-
numbered years.

¨

defined as beginning at [9:00 p.m./[time]] on the day the first day of Sukkot ends and end­ing at [9:00 p.m./[time]] the following day.

¨

¨ [Name of party A] ¨ [Name of party B] shall have the second day of Sukkot every year.

¨

¨ [Name of party A] ¨ [Name of party B] shall have the second day of Sukkot in even-numbered years and

¨ [Name of party A] ¨ [Name of party B] shall have the second day of Sukkot in odd-numbered years.

¨

defined as beginning at [4:00 p.m./[time]] on the day Shemini Atzeret begins and ending at [4:00 p.m./[time]] the following day.

¨

¨ [Name of party A] ¨ [Name of party B] shall have Shemini Atzeret every year.

¨

¨ [Name of party A] ¨ [Name of party B] shall have Shemini Atzeret in even-numbered years and

¨ [Name of party A] ¨ [Name of party B] shall have Shemini Atzeret in odd-numbered years.

¨

defined as beginning at [4:00 p.m./[time]] on the day Simchat Torah begins and ending at [9:00 p.m./[time]] the following day.

¨

¨ [Name of party A] ¨ [Name of party B] shall have Simchat Torah every year.

¨

¨ [Name of party A] ¨ [Name of party B] shall have Simchat Torah in even-numbered years and

¨ [Name of party A] ¨ [Name of party B] shall have Simchat Torah in odd-numbered years.

¨

defined as beginning at [4:00 p.m./[time]] on the day Hanukkah begins and ending at [9:00 p.m./[time]] the following day.

¨

defined as beginning at [4:00 p.m./[time]] on the day Hanukkah begins and ending at [9:00 p.m./[time]] eight days later.

¨

¨ [Name of party A] ¨ [Name of party B] shall have Hanukkah every year.

¨

¨ [Name of party A] ¨ [Name of party B] shall have Hanukkah in even-numbered years and

¨ [Name of party A] ¨ [Name of party B] shall have Hanukkah in odd-numbered years.

¨

defined as beginning at [4:00 p.m./[time]] on the day Purim begins and ending at [9:00 p.m./[time]] the following day.

¨

¨ [Name of party A] ¨ [Name of party B] shall have Purim every year.

¨

¨ [Name of party A] ¨ [Name of party B] shall have Purim in even-numbered years and

¨ [Name of party A] ¨ [Name of party B] shall have Purim in odd-numbered years.

¨

defined as beginning at [4:00 p.m./[time]] on the day of the first Passover Seder and end­ing at [4:00 p.m./[time]] the following day.

¨

¨ [Name of party A] ¨ [Name of party B] shall have the first Passover Seder every year.

¨

¨ [Name of party A] ¨ [Name of party B] shall have the first Passover Seder in even-
numbered years and

¨ [Name of party A] ¨ [Name of party B] shall have the first Passover Seder in odd-
numbered years.

¨

defined as beginning at [4:00 p.m./[time]] on the day of the second Passover Seder and ending at [4:00 p.m./[time]] the following day.

¨

¨ [Name of party A] ¨ [Name of party B] shall have the second Passover Seder every year.

¨

¨ [Name of party A] ¨ [Name of party B] shall have the second Passover Seder in even-numbered years and

¨ [Name of party A] ¨ [Name of party B] shall have the second Passover Seder in odd-numbered years.

¨

defined as beginning at [6:00 p.m./[time]] on the last day of Ramadan and ending at [6:00 p.m./[time]] the second day of Eid al-Fitr.

¨

¨ [Name of party A] ¨ [Name of party B] shall have Eid al-Fitr every year.

¨

¨ [Name of party A] ¨ [Name of party B] shall have Eid al-Fitr in even-numbered years and

¨ [Name of party A] ¨ [Name of party B] shall have Eid al-Fitr in odd-numbered years.

¨

defined as beginning at [6:00 p.m./[time]] on the day before Eid al-Adha begins and end­ing at [6:00 p.m./[time]] the second day of Eid al-Adha.

¨

¨ [Name of party A] ¨ [Name of party B] shall have Eid al-Adha every year.

¨

¨ [Name of party A] ¨ [Name of party B] shall have Eid al-Adha in even-numbered years and

¨ [Name of party A] ¨ [Name of party B] shall have Eid al-Adha in odd-numbered years.

¨

When it is a parent’s birthday, the birthday parent shall have that parent’s celebration during that parent’s regularly scheduled time with the child[ren].

¨

When it is a parent’s birthday, the birthday parent shall be entitled to have the child[ren] for up to three hours for a celebration on the birthday and shall give notice to the other parent of the birthday parent’s plan to exercise this option at least three days in advance.

¨

Other:       

      

¨

Child care       

¨

Preschool       

¨

Elementary school       

¨

Middle/junior high school       

¨

High school       

¨

Before or after school at       

¨

Study abroad       

¨

Summer school       

¨

Special education or tutoring       

¨

No changes in enrollment or participation shall be made without the consent of both par­ents.

¨

If the child[ren] [is/are] no longer eligible to attend an educational program in which the child[ren] [is/are] enrolled, ¨ [Name of party A] ¨ [Name of party B] shall have the responsibility to decide what program will be substituted, and the other parent will be given the right to attend and be informed of any pertinent meetings or testing related to the change in educational programs.

¨

Both parents shall provide the leaders of the educational programs and activities attended by the child[ren] with stamped, self-addressed envelopes sufficient for mailing copies of all communications during the year, if that is necessary to receive notices of events and report cards. If the program fails to agree to send separate notices, ¨ [name of party A] ¨ [name of party B] will notify the other parent of school events and activities and will provide copies of report cards within ____ days of receipt.

¨

Both parents shall be informed of any school trips and activities in which parental partic­ipation is permitted and ¨ both parents shall attend, if they both desire to attend –OR– ¨ the parents shall alternate, with [name of party A] attending the first activity day in even-numbered years and [name of party B] attending the first activity day in odd-
numbered years.

¨

At the beginning of a child’s senior year, [name of party A] and [name of party B] will dis­cuss with the child and consult with each other with respect to the post–high school edu­cation of the child, and [name of party A] and [name of party B] will discuss and attempt to come to an agreement on the costs, if not otherwise determined.

¨

[Name of party A] and [name of party B] agree to the following about college education of the child[ren]:
      

¨

¨ [Name of party A] shall pay ________% and ¨ [Name of party B] shall pay ________% of the cost of:
¨      Private school tuition
¨      Private school room and board
¨      All other expenses associated with school activities including:
            ¨ uniforms ¨ class trips ¨ activity fees ¨ book fees
            ¨ fees for AP classes ¨ transportation.

¨

The provision of education expenses will be considered child support and enforceable as such.

¨

The parents agree not to give permission to the child[ren] to engage in social activities that occur while the child[ren] [is/are] with the other parent.

¨

¨ [Name of party A] ¨ [Name of party B] shall have the right to enroll the child[ren] in _____ (number) extracurricular activities (including without limitation sports teams, music lessons, scouts, and the like) that may occur partially while the child[ren] [is/are] with the other parent, and the other parent agrees to make that parent’s best efforts to get the child[ren] to and from those activities during that time.

¨

The parents shall agree before enrolling the child[ren] in extracurricular activities that may occur partially while the child[ren] [is/are] with the other parent, and, if the parents are agreed, they shall make their best efforts to get the child[ren] to and from those activ­ities when the child[ren] [is/are] with that parent.

¨

Each parent shall make a good-faith effort to give information to the other parent about events and activities in the child[ren]’s life like school programs, concerts, award cere­monies, plays, sports events, and other events or activities in which the child[ren] [is/are] participating.

¨

Both parents will encourage the child[ren] to engage in the following extracurricular activities:
Activities for ______________________ (child’s name): ______________________
Activities for ______________________ (child’s name): ______________________
Activities for ______________________ (child’s name): ______________________

¨

Extracurricular expenses shall be paid by:
¨   [Name of party A]
¨   [Name of party B]
¨   Split as follows: ____% by [name of party A] and ____% by [name of party B]
¨      The parent who enrolled the child

¨

The child[ren] will be cared for by the following health-care providers:

Physician:       

Dentist:       

Orthodontist:       

Therapist:       

Other:       

¨

Each parent will deliver the medications of the child[ren] to the other parent at the begin­ning of the other parent’s parenting time, unless the medications have been divided by the pharmacist into two containers that provide appropriate dosages and administrations to cover the time with each parent or unless two prescriptions can be obtained.

¨

Each parent will inform the other of regular health-care appointments in advance, and both may attend.

¨

Each parent will notify the other of any significant event in the religious life of the child[ren], and the parents shall both be given the opportunity to attend.

¨

Before any change in the religious affiliation of a child, the parents will consult in advance, discuss the change with the child, and attempt to reach an agreement with respect to such a change.

¨

If there is no agreement to change the religious affiliation of the child[ren], each parent will decide what religious activities and practices the child[ren] will participate in during that parent’s parenting time periods.

¨

The parents agree not to enroll the child[ren] in summer camp(s) that occur while the child[ren] [is/are] with the other parent.

¨

¨ [Name of party A] ¨ [Name of party B] shall have the right to enroll the child[ren] in summer camp as long as it does not interfere with the other parent’s extended summer possession.

¨

The parents shall agree before enrolling the child[ren] in summer camp.

¨

Summer camp expenses shall be paid by:
¨   [Name of party A]
¨   [Name of party B]
¨   Split as follows: ____% by [name of party A] and ____% by [name of party B]
¨   The parent who enrolled the child

¨

The child[ren] may telephone and e-mail the other parent whenever the child[ren] want[s].

¨

The child[ren] may telephone the other parent at the following times: __________________ –OR– ¨ at least ________ times a week.

¨

The parent who is not with the child[ren] shall make an effort to talk at least ______ times a ¨ week ¨ month by calling the child[ren] at reasonable times.

¨

The parent who is with the child[ren] shall make the child[ren] available by telephone from ________ to ________ ¨ each day –OR– ¨ __________________ so that the other parent may talk to the child[ren].

¨

If a message is left from the parent who is not with the child[ren], the other parent shall assist the child[ren] in returning the call.

¨

Reasonable times to call the child[ren] at the other parent’s home are:
¨   between 8 a.m. and 8 p.m.
¨   between ______ ¨ a.m. ¨ p.m. and ______ ¨ a.m. ¨ p.m.

¨

Telephone calls and other communication shall not be monitored by the other parent unless either believes in good faith that a child is having a problem, in which case the parent shall advise the other parent that the call or other communication is being moni­tored.

¨

Telephone contact with the other parent shall not exceed _____ minutes in a 24-hour time frame.

¨

If a parent will be absent for more than ______________________while the child[ren] [is/are] in that parent’s care, then that parent shall notify the other parent, and the other parent will have the right to care for the child[ren] during that absence.

¨

However, this right of first refusal is not required to be offered if the child[ren]’s care is being provided by _________________________________.

¨

Subject to any right of first refusal, each parent shall be responsible for that parent’s own temporary babysitting arrangements, when such care is provided, as long as the following conditions are met:

¨   Each parent shall inform the other parent from time to time of the contact informa­tion for any and all persons or programs who may provide care for the child[ren].

¨   Each parent has the right to communicate with the person who is providing care for the child[ren].

¨   The following shall not be allowed to provide child care for the child[ren]: babysit­ters under the age of _____ and ________________________________________.

¨

If either parent becomes incapacitated or dies, the other parent shall ensure that the child[ren] continue to have contact with the extended family of that parent, including the following: ______________________________________________________________

¨

The parents agree that no person, other than a spouse, with whom the parent is involved in an intimate relationship shall spend the night when the child[ren] [is/are] in the par­ent’s care, unless
      
 _____________________________________________ (insert acceptable conditions).

¨

The parents agree to the use the following strategies for managing the child[ren]’s behav­ior:       

¨

Each will inform the other by means of a written list of the basic expectations for behav­ior (house rules) with which the child[ren] [is/are] expected to comply when spending time with that parent.

¨

Other agreements:       

¨

The parents agree to the following because of past circumstances involving:

¨   family violence and/or child abuse and neglect

¨   alcohol abuse and/or substance use disorder

¨

No report or record made available to ¨ [Name of party A] ¨ [Name of party B] may include the address of the other parent or the child[ren] if residing with the parent with the confidential address.

¨

All caregivers shall be notified of any restrictions regarding contact with the child[ren].

¨

¨ [Name of party A] ¨ [Name of party B] shall have supervised parenting time with the child[ren]. The parenting time shall be held at the following times:       
      

¨   And under the following directions:       

¨   The entire parenting time shall be supervised.

¨      Only the following portion of the parenting time must be directly supervised:
      
      

¨      The length of parenting time shall be:       
      

¨      The parenting time shall be supervised by:

            ¨   third party:       

¨   professional person/agency (specify):       
         

¨         mutually agreed third party

¨

Exchanges of the child[ren] shall be supervised by a mutually agreed upon:

¨   third party:       

¨      professional person/agency (specify):       
         

¨      for the beginning of parenting time

¨      for the end of parenting time

¨

¨ [Name of party A] ¨ [Name of party B] shall not have parenting time with the child[ren] at this time.

¨

¨ [Name of party A] ¨ [Name of party B] may maintain contact with the child[ren] through:

¨ phone ¨ letter ¨ mail ¨ other:

¨ daily ¨ weekly

¨

¨ [Name of party A] ¨ [Name of party B] may not have contact at this time.

¨

¨ [Name of party A] ¨ [Name of party B] agrees to engage in counseling with:       
      

¨

¨ [Name of party A] ¨ [Name of party B] agrees to engage in a custody evaluation with:       
      

¨

At the completion of the evaluation the provider shall submit a statement by affidavit acknowledging:

¨   the parent’s fitness to resume contact

¨   a recommendation for unsupervised parenting time

¨   a recommendation for continued supervision under specified condition

¨

¨ [Name of party A] ¨ [Name of party B] shall continue to attend a twelve-step or similar program and provide evidence to the other parent of such attendance.

¨

¨ [Name of party A]¨ [Name of party B] shall modify [her/his] behavior around the child[ren] in the following ways:

¨   [He/She] shall not operate a motor vehicle within _____ hours after consuming drugs or alcohol.

¨   [He/She] shall not consume alcohol or drugs within _____ hours before spending time with the child[ren].

¨   [He/She] shall not consume alcohol or drugs in the presence of the child[ren].

¨   [He/She] shall not allow others to consume alcohol or drugs in the presence of the child[ren].

¨   [He/She] shall submit to a drug and alcohol screening performed by ________________ on a ____________ basis for ____________ (time period).

¨    [ He/She] shall do the following:       
      

Forms 16-3 through 16-10 are reserved.