A parent has one or more of these problems as follows (check all that apply): Abandonment – (Parent’s name): intentionally abandoned a child listed in 2 for an extended time. Neglect – (Parent’s name): substantially refused to perform his/her parenting duties for a child listed in 2. Child Abuse – (Parent’s name): (or someone living in that parent’s home) abused or threatened to abuse a child. The abuse was (check all that apply): physical sexual repeated emotional abuse. Domestic Violence – (Parent’s name): (or someone living in that parent’s home) has a history of domestic violence as defined in RCW 26.50.010(1). Assault – (Parent’s name): (or someone living in that parent’s home) has assaulted or sexually assaulted someone causing grievous physical harm or fear of such harm. Sex Offense – (Parent’s name): has been convicted of a sex offense as an adult. Someone living in (parent’s name): ’s home has been convicted as an adult or adjudicated as a juvenile of a sex offense. b. Other problems that may harm the children’s best interests. (If a parent has any of these problems, the court may limit that parent’s contact with the children and right to make decisions for the children.) Neither parent has any of these problems. (Skip to 4.) A parent has one or more of these problems as follows (check all that apply): Neglect – (Parent’s name): neglected his/her parental duties towards a child listed in 2. Emotional or physical problem – (Parent’s name): has a long-term emotional or physical problem that gets in the way of his/her ability to parent. Substance Abuse – (Parent’s name): has a long-term problem with drugs, alcohol, or other substances that gets in the way of his/her ability to parent. Lack of emotional ties – (Parent’s name): has few or no emotional ties with a child listed in 2. Abusive use of conflict – (Parent’s name): uses conflict in a way that endangers or damages the psychological development of a child listed in 2. Withholding the child – (Parent’s name): has kept the other parent away from a child listed in 2 for a long time, without a good reason. Other (specify):
Christmas Day Odd Years Even Years Every Yr. Odd Years Even Years Every Yr. Begin day/time: Begin day/time: End day/time: End day/time: Follow the Winter Break schedule above. Other plan: New Year’s Eve / New Year’s Day (odd/even is based on New Year’s Day) Odd Years Even Years Every Yr. Odd Years Even Years Every Yr. Begin day/time: Begin day/time: End day/time: End day/time: Follow the Winter Break schedule above. Other plan: Children’s Birthdays Odd Years Even Years Every Yr. Odd Years Even Years Every Yr. Begin day/time: Begin day/time: End day/time: End day/time: Other plan: All three-day weekends not listed elsewhere (Federal holidays, school in-service days, etc.) The children shall spend any unspecified holiday or non-school day with the parent who has them for the attached weekend. Other plan: Other occasion important to the family: _________ Odd Years Even Years Every Yr. Odd Years Even Years Every Yr. Begin day/time: Begin day/time: End day/time: End day/time: Other plan: Other occasion important to the family: _________ Odd Years Even Years Every Yr. Odd Years Even Years Every Yr. Begin day/time: Begin day/time: End day/time: End day/time: Other plan: