Minor Child Custody Mediation Agreement Form
Use this form to outline proposed custody arrangements, parenting time, exchange details, and decision-making preferences for a minor child mediation agreement.
Parent / Guardian Information
First Parent/Guardian Full Name
*
First Name
Last Name
Second Parent/Guardian Full Name
*
First Name
Last Name
Child Information
Child Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Custody Arrangement Details
Preferred custody schedule
*
Shared physical custody
Primary custody with visitation
Primary custody without visitation
Split custody
Bird's nest arrangement
Other
Preferred parenting-time exchange schedule
*
Transportation / exchange location details
*
Agreement Confirmation
Mediation Terms Acknowledged
*
I understand this agreement is for mediation purposes only and that the details entered reflect our proposed arrangement
Signature Name
*
Submit Agreement
Should be Empty: