SHELTER CARE APPLICATION

______________________, a Minor "Child" 

In the Interest Of: 

Your petitioner avers that it would be contrary to the welfare, safety and health of the Child to remain under the 

To the Honorable Judge of said Court: 

care of 

The Child 

The facts which support allegations of dependency are: 

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 pages attached 

AOPC Form Updated 1/10/2017  

Shelter Care Application, Page 1 of 2 

 The petitioner avers that reasonable efforts were made to prevent the placement of the Child. The following 

efforts were made to prevent the placement of the child: 

SHELTER CARE APPLICATION 

 Additional pages attached. 

 The petitioner avers that 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 petitioner avers that there are no less restrictive alternatives available, because: 

 The petitioner avers that the following Family Finding efforts were made: 

 The petitioner avers that the following family members were contacted: 

 The anticipated placement of the Child is: 

 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. 

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 

AOPC Form Updated 1/10/2017 

Shelter Care Application, Page 2 of 2