Name: 

Name: 

 

Race:   

Address:

 

 Asian/Pacific Islander 
 Black  
 Caucasian  

FILING TYPE 
 APPLICATION FOR EMERGENCY PROTECTIVE CUSTODY 
PETITIONER / AGENCY 
 
 
Address:   
 

Phone: 

 

 

IN THE INTEREST OF: 
 

Age: 

DOB: 

 

Sex: 

 

Phone Number(s):  

Phone Type:  

 
 

 Bi-Racial 
 Native   Tribal Affiliation:   
 Unknown/Unreported 

 

CASE INFORMATION 

Ethnicity: 

 
 
 Hispanic  
 Not Hispanic 
 Unknown 

   

 

 

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  
Abuse: 

 The petition alleges that the above named child is a victim of child 

abuse as defined at 23 Pa.C.S. §6303. 

 (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)  

 Child is NOT in Protective Custody 
 
Location of the child is: 
 Child remains in home but is in imminent risk of placement 
in foster care absent preventive services. 

under supervision of the county agency 
                   Time: 
Date: 
 
Location of the child is: 

 

 Child is in Protective Custody (removed from the home) and 

CHILD’S PARENTS AND/OR OTHER LEGAL GUARDIAN OR CUSTODIAN 

Protective Custody: 

Phone Number(s):  Phone Type: 

Phone Number(s):  Phone Type: 

Phone Number(s):  Phone Type: 

Mother’s Name:  

 
DOB: 

 

Address: 

 

Father’s Name: 

 
DOB: 

 

Address: 

 

 
 

 
 
 

 
 
 

 
 
 
   Whereabouts Unknown 
  Closest Relative – If whereabouts unknown for Parents and Guardian 
Name: 
 
Address: 
Phone Number: 
Relation to Child: 

 
 
 
   Whereabouts Unknown 

 

 

 

Legal Guardian’s or Custodian’s Name: 

 DOB: 

 

 
Relationship: 

Address: 

 

 
 

 
 
 

 
 
 
   Whereabouts Unknown 

  Additional Participants with Relationship to Child 

(see attached) 

Attorney’s Name: 

 

Address: 

 

Supreme Court ID: 

 

CHILD’S ATTORNEY/GUARDIAN AD LITEM 
Guardian Ad Litem’s Name: 

 

Address: 

 

 

Supreme Court ID: 

 

 
 

 

AOPC Form Updated Rev 8/30/2010                                

 

 Emergency Application, Page 1 of 4 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Commonwealth of Pennsylvania 
Court of Common Pleas – Juvenile Division 
County of [Name] 

 Judicial District 

       

In the Interest Of: 
______________________, a Minor 

 

 
Docket No: CP-
 
FID:       
  County Local No: ___________________ 

-DP-
-FN-

-20
-20

 
ADDITIONAL PARTICIPANTS WITH RELATIONSHIP TO CHILD  

In the Interest Of: 
______________________, a Minor 

Name 

DOB 

Relationship to Child 

Address 
(Indicate if Whereabouts 
Unknown) 

Phone 
(indicate type  
ex: Cell Phone) 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

   

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

   

   

   

   

   

   

   

 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

AOPC Form Updated Rev 8/2/2010                                        

  

Emergency Application, Page 2 of 4 

In the Interest Of: 
______________________, a Minor 

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

o 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. 

 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. 
 

pecifically, on or about (date or time period): 

(State the facts supporting the allegations. Attach additional pages if necessary.) 

 Additional Allegations attached 

 

  S

 

 

  T

 
 
 
 
 
 
 
 
 
 

AOPC Form Updated Rev 8/2/2010                                        

  

Emergency Application, Page 3 of 4 

In the Interest Of: 
______________________, a Minor 

he 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 

  

 

    T

 

 

 
 
 
 
 
 
 
 
 
 

AOPC Form Updated Rev 8/2/2010                                        

  

Emergency Application, Page 4 of 4