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Appendix B: Sample Custody and Visitation Order SAMPLE CUSTODY and VISITATION ORDER COMMONWEALTH OF PENNSYLVANIA Division : : : Plaintiff : v.. : : Defendant : Docket No. ORDER AND NOW, this day of , 200, after hearing OR pursuant to the agreement of the parties the following order is entered with respect to the child(ren): Date of Birth Full Name 1.. Holidays are to include (check all that apply): Christmas Eve New Year s Eve Martin Luther King Day Passover Fourth of July Rosh Hashanah Columbus Day Christmas Day New Year s Day Easter Memorial Day Labor Day Yom Kippur Thanksgiving OR The parties shall observe the following holiday schedule (be specific as to exchange times, start date, and other relevant details): PAGE 5 4.2.. (select all that apply) Each party shall be entitled to spend uninterrupted weeks with the child(ren) during summer vacation from school, provided that 30 days written notice is provided to the other party and that the time selected does not conflict with similar time for which the other party has already given proper notice..
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