SUPERIOR COURT OF CALIFORNIA County of Marin AGREEMENT OF NON-PROFESSIONAL PROVIDER TO SUPERVISE CHILD VISITATION CASE NUMBER: PETITIONER: ADDRESS: ATTORNEY: ADDRESS: HOME NO.: WORK NO.: CELL NO.: HOME NO.: WORK NO.: CELL NO.: RESPONDENT: ADDRESS: ATTORNEY: ADDRESS: HOME NO.: WORK NO.: CELL NO.: HOME NO.: WORK NO.: CELL NO.: OTHER INTERESTED PERSON/ENTITY: ADDRESS: TELEPHONE NUMBERS: Please indicate your agreement by checking each box in front of each numbered paragraph. ˆ 1. I agree to act as a visitation supervisor for visitation between _________________________________________, parent/guardian and _______________________________________________________________________________, minor child/child(ren), under the court order dated _________________________, a copy of which has been given to me. ˆ 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 neutrally and without any bias or favoritism toward or against the supervised person. ˆ 3. I agree that I will not, under any circumstances, leave the minor child or children with the supervised person outside my presence. ˆ 4. 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 Information About Obligations of Visitation Supervisor sheet (form FL036) and, if ordered by the court, on all the observations I make during the visits. ˆ 5. I have received a copy of the Guide for the Non-Professional Provider of Supervised Child Visitation (form FL039) given to me by this court, Family Law Facilitator, Parent Coordinator, or Family Court Services. I 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. ˆ 6. I have received a copy of each document: Agreement of Non-Professional Provider to Supervise Child Visitation (form FL037), the Guide (form FL039), and Information About Obligations and Visitation Log (form FL036). I understand and agree to comply with each of the provisions in each document. ˆ 7. 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 understand that no supervision will take place until the visitation supervisor has signed this Agreement. A copy of the signed Agreement shall be provided to the custodial parent and to Family Court Services. DATE SIGNATURE OF SUPERVISED PARENT OR GUARDIAN DATE SIGNATURE OF NON-PROFESSIONAL VISITATION SUPERVISOR PRINT NAME OF VISITATION SUPERVISOR ADDRESS TELEPHONE NUMBER FL038 AGREEMENT OF NON-PROFESSIONAL PROVIDER TO SUPERVISE VISITATION Rev. 3/09 American LegalNet, Inc. www.FormsWorkflow.com