ALA FL-015 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar number, and address) FOR COURT USE ONLY TELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NO. (Optional): SUPERIOR COURT OF CALIFORNIA, COUNTY OF ALAMEDA STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME PETITIONER: RESPONDENT: OTHER: CASE NUMBER: AGREEMENT FOR CHILD VISITATION SUPERVISION 1. I (name of visitation supervisor):_________________________________________________________ agree to act as a supervisor for visitation between (name of parent/guardian):_______________________________________________________________ and (name of minor child/children): ________________________________________________________________________________. under the court order dated __________________________, a copy of which has been given to me. 2. I understand that my principal responsibility is to observe these visits in person and to take action immediately if the minor child(ren) needs protection, reassurance, or a break of any kind from the visit. I agree to perform my duties as a visitation supervisor dispassionately and without any bias or favoritism toward or against the supervised person. 3. I agree that I will report to the court or, if ordered by the court, to Family Court Services, if the supervised person violates any of the rules described on the Guidelines for Child Visitation Supervision (form ALA FL-015-INFO) and, if ordered by the court, on all the observations I make during the visits. 4. I agree that I will not, under any circumstances, leave the minor child or children with the supervised person outside my presence. 5. I have received a copy of the Guidelines for Child Visitation Supervision given to me by this court, understand them, and agree to follow them. Specifically, I have read and understood my obligation to report any child abuse or any reasonable suspicion of child abuse to Child Protective Services. 6. I understand that if I fail to follow this agreement, I may be held in contempt of this court; I may put the safety of the minor child(ren) at risk; and I may make it difficult or impossible for the supervised person to continue to have visitation. I have received copies of this Agreement for Child Visitation Supervision and the Guidelines for Child Visitation Supervision. I understand and agree to comply with each of the provisions in the two forms. I understand that no supervision will take place until the visitation supervisor has signed the Agreement for Child Visitation Supervision. Date: ___________________________________________________ SIGNATURE OF SUPERVISED PARENT OR GUARDIAN Date: ___________________________________________________ SIGNATURE VISITATION SUPERVISOR ___________________________________________________ ___________________________________________________ ___________________________________________________ ADDRESS AND PHONE NUMBER OF VISITATION SUPERVISOR Page 1 of 1 Form Approved for Mandatory Use Superior Court of California, County of Alameda ALA FL-015 [New January 1, 2009] AGREEMENT FOR CHILD VISITATION SUPERVISION Pen. Code § 11160; Standards of Judicial Administration § 5.20; Local Rule 5.20 American LegalNet, Inc. www.FormsWorkflow.com