Commonwealth of Pennsylvania Court of Common Pleas ­ Juvenile Division County of [Name] Judicial District In the Interest Of: ______________________, a Minor Docket No: CP- -DP-20 FID: -FN-20 County Local No: ___________________ FILING TYPE APPLICATION FOR EMERGENCY PROTECTIVE CUSTODY PETITIONER / AGENCY Name: Address: Phone: IN THE INTEREST OF: Name: Address: Age: Phone Number(s): DOB: Sex: Phone Type: Race: Asian/Pacific Islander Black Caucasian Bi-Racial Native Tribal Affiliation: Unknown/Unreported Ethnicity: Hispanic Not Hispanic Unknown CASE INFORMATION Type of Dependency: The child named above comes within the jurisdiction of the court as defined by The Juvenile Act at 42 Pa.C.S.§6302. Abuse and/or Neglect Status Offense (1) is without proper care or control (2) has been placed for care or adoption in violation of law (3) has been abandoned (4) is without a parent, guardian, or legal custodian (10) is born to a parent whose parental rights with regard to another child have been involuntarily terminated (5) while subject to compulsory school attendance is habitually and without justification truant from school (6) has committed a specific act or acts of habitual disobedience (7) is under the age of ten years and has committed a delinquent act (8) has been formerly adjudicated dependent, and is under the jurisdiction of the court (9) has been referred pursuant to section 6323 (relating to informal adjustment), and who commits an act which is defined as ungovernable in paragraph (6) Abuse: The petition alleges that the above named child is a victim of child abuse as defined at 23 Pa.C.S. §6303. Protective Custody: Child is NOT in Protective Custody Child is in Protective Custody (removed from the home) and Location of the child is: under supervision of the county agency Date: Time: Child remains in home but is in imminent risk of placement in foster care absent preventive services. Location of the child is: CHILD'S PARENTS AND/OR OTHER LEGAL GUARDIAN OR CUSTODIAN Mother's Name: DOB: Address: Father's Name: DOB: Address: Legal Guardian's or Custodian's Name: Relationship: Address: DOB: Phone Number(s): Phone Type: Phone Number(s): Phone Type: Phone Number(s): Phone Type: Whereabouts Unknown Whereabouts Unknown Closest Relative ­ If whereabouts unknown for Parents and Guardian Name: Address: Phone Number: Relation to Child: Attorney's Name: Address: Supreme Court ID: Whereabouts Unknown Additional Participants with Relationship to Child (see attached) CHILD'S ATTORNEY/GUARDIAN AD LITEM Guardian Ad Litem's Name: Address: Supreme Court ID: American LegalNet, Inc. www.FormsWorkFlow.com AOPC Form Updated Rev 8/30/2010 Emergency Application, Page 1 of 4 In the Interest Of: ______________________, a Minor ADDITIONAL PARTICIPANTS WITH RELATIONSHIP TO CHILD Address (Indicate if Whereabouts Unknown) Phone (indicate type ex: Cell Phone) Name DOB Relationship to Child American LegalNet, Inc. www.FormsWorkFlow.com AOPC Form Updated Rev 8/2/2010 Emergency Application, Page 2 of 4 In the Interest Of: ______________________, a Minor To the Honorable Judge of said Court: Your petitioner avers that it would be contrary to the welfare, safety and health of the child to remain under the care of . The facts which support allegations of dependency are: The child 1) is without proper parental care or control, subsistence, education as required by law, or other care or control necessary for his/her physical, mental, or emotional health, or morals; a determination that there is a lack of proper parental care or control may be based upon evidence of conduct by the parent, guardian or custodian that places the health, safety or welfare of the child at risk, including evidence of the parent's, guardian's or other custodian's use of alcohol or a controlled substance that places the health, safety or welfare of the child at risk; 2) has been placed for care or adoption in violation of law; 3) has been abandoned by his/her parents, guardian or other custodian; 4) is without a parent, guardian or other custodian; 5) while subject to compulsory school attendance is habitually and without justification truant from school; 6) has committed a specific act or acts of habitual disobedience of the reasonable and lawful commands of his/her parent, guardian, or other custodian and who is ungovernable and found to be in need of care, treatment or supervision; 7) is under the age of ten and has committed a delinquent act; 8) has been formerly adjudicated dependent, and who is under the jurisdiction of the court, subject to its conditions or placements and who commits an act which is defined as ungovernable; or 9) has been referred pursuant to an Informal Adjustment and who commits an act which is defined as ungovernable; 10) is born to a parent whose parental rights with regard to another child have been involuntarily terminated under 23 Pa.C.S. § 2511 (relating to grounds for involuntary termination) within three years immediately preceding the date of birth of the child and conduct of the parent poses a risk to the health, safety or welfare of the child. Specifically, on or about (date or time period): (State the facts supporting the allegations. Attach additional pages if necessary.) Additional Allegations attached Reasonable Efforts were made to prevent the placement of the child and there are no less restrictions. Preventive services were not offered due to the necessity for emergency placement. The lack of services was reasonable under the circumstances. This level of effort was reasonable due to the emergency nature of the situation, safety considerations, and circumstances of the family. The agency has determined it would pose a risk to the safety of the child or guardian to release the current whereabouts of the child. American LegalNet, Inc. www.FormsWorkFlow.com AOPC Form Updated Rev 8/2/2010 Emergency Application, Page 3 of 4 In the Interest Of: ______________________, a Minor The Petitioner verifies and acknowledges that the facts set forth in the petition are true and correct to the petitioner's personal knowledge, information, or belief, and that any false statements are subject to penalties of the Crimes Code, 18 Pa.C.S. § 4904, relating to unsworn falsification to authorities. PETITIONER NAME/TITLE ATTORNEY NAME PETITIONER SIGNATURE ATTORNEY SIGNATURE DATE DATE American LegalNet, Inc. www.FormsWorkFlow.com AOPC Form Updated Rev 8/2/2010 Emergency Application, Page 4 of 4