IN THE FAMILY COURT OF ________________ COUNTY, WEST VIRGINIA. In Re: The Marriage / Children of: Civil Action No. ____________ _________________________, and _________________________. Petitioner Respondent _________________________ _________________________ _________________________ _________________________ Address Address _________________________ _________________________ Daytime phone Daytime phone Worksheet for Individual Proposed Parenting Plan This Worksheet completed by: ____________________________ Date: _________ (Print your name.) PARENTING RESPONSIBILITIES Complete the following list which shows how you and the other parent have shared parenting responsibilities in the last twelve months before your divorce was filed. Do not provide information for any time after the filing of the divorce. This list is for the children named: ________________________________________. (A) Daily physical needs and care. Examples: feeding; bedtime and wake-up routines; care when child is sick or hurt; bathing, grooming, personal hygiene, dressing; recreation and play; physical safety; transportation. Mother ___% Father ___% (B) Developmental needs. Examples: learning to walk, talk, and use eating utensils; toilet training; development of self-confidence and maturity. Mother ___% Father ___% (C) Development of proper behavior. Examples: discipline; instruction in manners; assignment and supervision of chores. Mother ___% Father ___% (D) Educational matters. Examples: making school arrangements; communicating with teachers and counselors; supervision of homework; monitoring grades and discussing school related matters. Mother ___% Father ___% SCA-FC-128 (12/01) Worksheet for Individual Proposed Parenting Plan Page 1 of 4>>>> 2(E) Development of social skills. Examples: teaching the child how to develop proper personal relationships with friends, brothers and sisters, and adults. Mother ___% Father ___% (F) Health care. Examples: Making arrangements and appointments for health care; accompanying child to doctors and dentists appointments; discussing childs health care needs with doctors, dentists, and other health care providers; providing care in the home when child is ill. Mother ___% Father ___% (G) Moral and religious matters. Examples: Discussing moral and religious matters with the child; providing moral and religious guidance; accompanying the child to church. Mother ___% Father ___% (H) Child care matters. Examples: Making arrangements for child care by family members, baby-sitters, or child care facilities; supervising and communicating with these child care providers. Mother ___% Father ___% MAKING MAJOR DECISIONS FOR THE CHILDREN Explain how you and your spouse have shared the responsibilities for making major decisions for your children. This information is for only the last twelve months before your divorce was filed. Do not provide information for any time after the filing of the divorce. 1. First, review the types of decisions in the list, then answer the following question. Did you and your spouse always make the types of major decisions on the list by talking the decision over, and coming to an agreement on what the decision should be? ___ Yes ___ No If you answered Yes, you dont need to complete the list; youre finished with this section. If you answered No, read item. 2 2. Complete the list by indicating the percentage of time each type of decision was shared, which means you and your spouse talked the decision over and came to an agreement on the decision; or the percentage of time each type of decision was made Mother, or Father, alone, without talking it over. For each type of decision, the numbers in all of the blanks should always add up to 100. In items (F) and (G), you may write in other types of major decisions, and complete those items just as you completed the first part of the list. This list is for the children named: ________________________________________. (A) Education. Shared ___% Mother ___% Father ___% (B) Non-emergency health care. Shared ___% Mother ___% Father___% (C) Religion. Shared ___% Mother ___% Father ___% (D) Child care. Shared ___% Mother ___% Father ___% SCA-FC-128 (12/01) Worksheet for Individual Proposed Parenting Plan Page 2 of 4>>>> 3(E) School related activities. Shared ___% Mother ___% Father ___% (F) _____________________ Shared ___% Mother ___% Father ___% (G) _____________________ Shared ___% Mother ___% Father ___% PARENTS CURRENT WORK SCHEDULES List your current work schedule. Complete only the part on your work schedule. Mothers Work Schedule ________________________________________________________________________ _____________________ ________________________________________________________________________ _____________________ ________________________________________________________________________ _____________________ Fathers Work Schedule ________________________________________________________________________ _____________________ ________________________________________________________________________ _____________________ ________________________________________________________________________ _____________________ CHILDRENS SCHOOL, AFTER SCHOOL & SPORTS ACTIVITIES List your childrens current school, after school activity, and sports schedules. School includes pre-school and kindergarten programs. Explain when and how the children go to school and other activities, and when and how they come home. ___ None of our children attend school, pre-school, or kindergarten. This list is for the children named: ________________________________________. ________________________________________________________________________ _____________________ ________________________________________________________________________ _____________________ ________________________________________________________________________ _____________________ ________________________________________________________________________ _____________________ ________________________________________________________________________ _____________________ CHILD CARE Explain the arrangements for child care currently provided to your children by persons other than the parents. Explain who provides child care, and explain the child care schedule. ___ None of our children receive child care from any person other than the parents. SCA-FC-128 (12/01) Worksheet for Individual Proposed Parenting Plan Page 3 of 4