Vermont Parental Rights and Responsibilities Stipulation and Order Form

In this form, the minor children involved in the divorce are named. Moreover, the parents’ time with the children are scheduled in this form. The holidays, vacations, and weekends reserved for each parent are indicated. Download

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Form 825

Vermont 
Docket Number

County

Family Court 
PARENTAL RIGHTS AND RESPONSIBILITIES STIPULATION AND ORDER
 
Defendant

Plaintiff

V.

CHILDREN WHO ARE SUBJECT TO THIS ORDER:

1. Legal Responsibility: 
Legal Responsibility is the responsibility to determine and control various matters relating to a child's

welfare and upbringing, including education, non-emergency medical and dental care, religion and travel 
arrangements. Legal responsibility can be held solely by one parent or shared jointly by both parents. If it is

shared jointly, you should be able to make decisions by agreement and the court must determine that you can do 
so. 
We agree that legal responsibility for our child(ren) shall be:

shared jointly by both parents; or 
Name of Parent

held solely by

2. Physical Responsibility: 
Physical responsibility is the responsibility to provide the routine daily care of a child. Physical
responsibility can be held solely by one parent or may be divided or shared. If physical responsibility is held
solely by one parent, it is subject to the other parent's right to parent child contact.

We agree that physical responsibility for our child(ren) shall be:

shared jointly by both of us; or 
Name of Parent

held solely by

Pursuant to Vermont law (15 V.S.A. Sec. 670), both parents shall have full access to the medical,

dental, law enforcement and school records relating to the minor child(ren). 
Grade
Date of Birth

Last Name

M.

First Name 
Last Name

Grade

Date of Birth

M.

First Name 
Last Name

Grade

Date of Birth

M.

First Name Grade

Last Name 
Date of Birth

First Name

M. 
Grade

Last Name

Date of Birth

First Name

M. 
Grade

Date of Birth

M.

Last Name 
First Name

3. Access to Records 
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Form 825 Page 2

4. Parent Child Contact Schedule

Name of Parent

parent,

When one

has primary or sole physical responsibility,

Name of Other Parent

shall have the right to visit with the child(ren)
according to the following schedule:

and at other times as agreed to by the parties. 
When both parents share physical responsibility, the parents shall share the right to spend time with the

child(ren) according to the following schedule:

5. Vacations and Holidays 
We make the following agreement concerning our right to be with our child(ren) on holidays and school
vacations : (please specify the holidays and vacations on which special visitation arrangements have been agreed to,
including the substance of the agreement and which year it begins; for example: Thanksgiving day will be alternated,

with mother having the children the first year, or Christmas eve and Christmas day will be shared as follows:)

6. Transportation and Travel Arrangements: 
Transportation responsibilities including the costs and method of travel for the child(ren) from one parent
to the other and out of state travel shall be as follows:

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A PERSON WHO FAILS TO COMPLY WITH ALL TERMS OF THE CURRENT ORDER
GOVERNING PARENT-CHILD CONTACT MAY BE SUBJECT TO CONTEMPT OF COURT
CHARGES.  THE COURT MAY IMPOSE ADDITIONAL REMEDIES, INCLUDING A
MODIFICATION OF THE CURRENT PARENT-CHILD CONTACT ORDER IF FOUND TO BE
IN THE BEST INTERESTS OF THE CHILD. (15 VSA, Section 668a (f))

Form 825 Page 3

7. Communication Regarding the Child(ren):

We shall communicate with each other concerning, the child(ren) on a regular basis; or

We shall communicate with each other concerning the child(ren) as follows (please state any special 
conditions or restrictions concerning communication about the child(ren)):

8. Procedure for Resolving 
Disputes:

We agree to try to resolve any disputes we have in the future concerning the child(ren) through 
mediation before coming back to the court; or
We agree to use the following procedure to resolve future disputes instead of mediation:

9. Other Agreements Concerning the Child(ren): 
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Form 825 Page 4

The parties stipulate to the agreements listed above. 
Date

Plaintiff's Signature 
Date

Defendant's Signature 
Approved as to form:

Attorney for Plaintiff

Attorney for Defendant 
Date

Date
ORDER RE: PARENTAL RIGHTS AND RESPONSIBILITIES
The terms of the stipulation set forth above are hereby incorporated into an

ORDER RE: PARENTAL RIGHTS AND RESPONSIBILITIES in this matter and shall remain in full

force and effect until further order of the court.

Family Court Judge
Date
Assistant Judge
Assistant Judge

Date

Date
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