HomeMy WebLinkAbout94-02347
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JODY L. BRIDGE
Plaintiff
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
V
DEBORAH W. BRIDGE
NO. 94-2347 CIVIL TERM
IN CUSTODY
ORDER OF COURT
AND NOW, May 6, 1994, pending a hearing before the custody
conciliator, the court sets a hearing for Thursday, May 19, 1994
at 3:00 p.m. to determine if temporary custody of the children
should be placed with Jody L. Bridge until the custody
conciliator renders a decision in this case.
The court will only hear testimony of events occurring since
January 1, 1994 at the hearing.
Since the allegations also involve the boy friend of the
mother, she is directed to produce him for testimony at the
hearing.
By the Court,
/ '{
.J.
Barbara J. Yunis, Esquire
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ORDBR OF COURT
~D
this
1994,
upon
day of
NOW
presentation and consideration of the within Petition for Special
Relief, it is hereby ordered that the above named plaintiff,
Jody L. Bridge, shall have primary physical and legal custody of
the parties' children, Kale Cendall Bridge, born April 7, 1986
and Brice Elliott Bridge, born September 21, 1987, pending
further Order of Court or agreement of the parties.
It is
specifically understood that the Plaintiff will provide the
Defendant with reasonable, liberal and appropriate periods of
contact with the children pending further Order of Court or
agreement. In the event that the Defendant is not provided with
sufficient time with the children, she may file a Petition for
special Relief or otherwise request the Court to review the
within Petition and this Order by hearing or conference with
counsel for the parties.
BY THE COURT,
J.
vs.
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
NO. CIVIL 1994
JODY L. BRIDGE,
Plaintiff
DEBORAH W. BRIDGE,
Defendant
IN CUSTODY
PETITION POR SPBCIAL RBLIIl
PURSUANT TO SBCTION 1915.13
AND NOW comes Petitioner, Jody L. Bridge, by and through his
counsel of record, Barbara J. yunis, Esquire, and petitions the
Court as follows:
1. Your Petitioner is Jody L. Bridge, the above named
Plaintiff, an adult individual residing at P.O. Box 352, 5 Front
Street, Boiling springs, Cumberland county, Pennsylvania.
2. The Respondent is the above named Defendant, Deborah W.
Bridge, an adult individual currently residing at 1226 Claremont
Road, Carlisle, Cumberland County, Pennsylvania. r I
i'c.hfl~c.....lt.~~lri(Q.+1cJYlclt D)'
3. Your Petitioner filed a ('Ol"{',...r~t- -Pm- CUstody
contemporaneously with requesting that he be given
primary
physical and legal custody of the parties' children, Kale Cendall
Bridge, born April 7, 1986 and Brice Elliott Bridge, born
September 21, 1987, pending the custody conciliation in this
matter or further Order of Court. The parties are subject to a
custody agreement which is referred to in paragraph 12 of the
Property Settlement Agreement, effective November 6, 1989, a copy
of which is attached hereto and incorporated herein by reference
as Exhibit "A".
4. Although Respondent has had primary physical custody of
the children since the parties' divorce in 1989, the Petitioner
has had continuous visitation with his children.
5. Since the parties' divorce in 1989, the Respondent
had a history of residing with various boyfriends who have
abusive and/or associated with drugs.
6. Your Respondent has shown an inability to properly care
for the children or properly provide for them in the following
has
been
means:
(A) Respondent has continually and repeatedly allowed
boyfriends, who are both verbally and physically abusive, to
reside with her and the children in their home~
(8) CUrrently, Respondent is residing with her fiance,
Hilton stackfield, who is verbally and physically abusive towards
Respondent~
(e) Over the past few years, Respondent's fiance,
has assaulted Respondent in the presence of the children and on
numerous other occasions~
(D) The pOlice department has responded to four
incidents in the last four months regarding the domestic violence
at Respondent's home~
(E) On at least one occasion, Respondent
taken to the hospital in the middle of the night to
for injuries caused by her fiance~
(F) Petitioner believes these conditions are
stressful and disruptive for the children and fears for
children's safety~
has been
be treated
very
the
allow
(G) Despite
Stackfield
the violence,
to reside with
Respondent continues
the children at
to
her
Mr.
residence;
(H) It is believed, at present, Mr. Stackfield is
serving time in the Cumberland County Jail. However, if his bail
is posted, Petitioner believes Respondent will allow Mr.
Stackfield to return to her home as she has done repeatedly in
the past; and
physically
Respondent.
WHEREFORE, Petitioner requests your Honorable Court to enter
an Order providing him with temporary physical custody of the
parties' children pending a final resolution of this matter
through further Order of Court or agreement.
Respectfully submitted,
GRIFFIE & ASSOCIATES
(I) Petitioner is fearful the children will
and mentally harmed if they continue to reside
be
with
BY
I verify that the statements made in the foregoing document
are true and correct. I understand that false statements herein
are made subject to the penalties of 18 Pa.C.S. Section 4904,
relating to unsworn falsification to authorities.
DATE: ~-/;. 1<,'1'
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PROPeRlY S!Tr1.P.H1<JlT AGiU!IlKP:1fT
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TllI~ AC:R":f.";::m:, ,lqt,,1 rhp .Q~ ,In'! ,.r __!{Q'i~ I'lJi, hy IIn"
bl!t"l!l!11 -'!iD'l LYNN BRIDeI';, redrling ,~t R.O, 41. or-x "a6, Shermana Dale,
r..rry r.~lInty, .Pl!nn~ylv',"ill, !hlCilll S"o::urilY Nuon!-- In&-<Fi-7256,
hl!rpiMCt'!r called th.. "Hllshand", and DEBORAH W. IIRIDG!;:, formerly WEIBLEY,
rp'qiclin~ nt 122" ClItrl'mont Rnnd, C'Irttslp., Cllmh..rlnn<l County,
Penn8ylvnnill, SQc;t'l1 Security Numher lq6-48-2679, hl'reinafter called the
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"Wif..", who II~':.I!P. aa f"l1ows:
WIT ~ E r. S F. T H
~IIEI\F.AS, the "artil" lire "usll",,,, nnel Wif.., 1.,vin~ ''''I'll m'lrril!ll nn
g~('lt~mhl'r 1.9, 198/., in Shp.t''''<1~'' nod,., P"'r-r'Y r.ntlnty. P"nn!'toltv,ni.,.. Th,.
rnrti"" "~rnrnt.." 1111, IS, I~A~.
,"lIIER:::t\~. clunol!' h:1vi! h,..,ln i~'''IIC' or th" mn~t"i~p'f\t t'n ",i.:: KAI,f': CEND^r~T.
ilK rOGE, horn ~,pri 1 7, I ?ilFi, nne! RRT C::: F:I.I'-Inrr p.n lilm:, hnrn S"rtl'mb"r 21,
lO~7, h~r~innFt~r r~ferrPf! to ~~ th~ rhii~ren.
WIIF.nF.^~. ",'fth:?"r1 :1ntJ ~o/i r" :'1r~ ,''''<r:irol'CI nf ...,.,,\drli,,~ Ft"T t.....
dit;pn",iti,," f'f .,11 thl'ir .q!l'~t"!tR ;1'1 ('C'nt~mrl:'1t'if\n nr r"'rmi":1~inp thpir
m." rT i.'~P; :1n:i
{.111;::'RF.,\5" Itnoqhand o:In,t tlifl'! h:1vp. m:HI~ " r-nmrllOf"p .fi~clnRII"'p. to .....'ch
.~~;I"'r ilf ,11 :'I~cr~t.q t~.,t t~r:ay hntrf ~itl'#'r in'li'ddtl,l~'1 ("Ir :1:'1 ini",: tan:tnr:y
\.~ir.lI ("'el: ....'h,..- :;",1 hnth ?,'rt:i~~ .,c:j.o!l.*)",'t"'~~t'" 1"11,,. th"'~. 11""" h.."t .'to
"l~:'t.rt''1:1~ty t., go ;"'I"!'T.' ~:li", ,;lq-:i..,!1l1-.... ...'irt. .'" '~tl~r"~t;~ .'1"1i
N(H~, .:.11!~'1r.::-0Kr::. 7!1~!~ ..r.~fo~F:HF.NT '..;rf:l7.;~::;F'I'!~ rh"tt r"r" ."!n,1 ;n
conq i,tr.rllt. i ~n ,.,f th,. prn!":i!;~~ ro.l C')v"':"p'nt~ h....,.~ tra r.nnt.1; "I'lrt nn,-1 i"t~nrlinR
EXHIBIT "A"
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tn be Ip.glllly bound hereby, it is agreed by and b~tween the parties hereto
,'s fo llow~:
I, WAIVER 01' CLAIHS ACAIRST ESTATE
lIusbnnd hereby waives his rillht of election tn take against the will
n. Wifp. nnd Wife hereby wnive~ hpr right to take 8gain~t the Will of
Hu.hnncl: 8nicl w'Iiver of right to l!lect ill mnclp. in accorclancl' with thl!
Probntl!, Eatatp.ll IInd 'icluclarie~ CadI!, Act nf 1972, Junp. 30, P.L. 508, Ro.
I Fit. , 20 Pa, C.S.A';-12207.
Shn..l.1 "ith..r lIush"n<\ nr Wife <Ii" w;thollt "Will, Ih,qh"nd hpr"by
wnlvps the right, title '1nd intl!rpqr h" millht hnvl! in thp estate nf Wire
nnd Wifp. hereh, wnives the riRht. titll' nnd int"r".t .hl! might have in the
".tnt.. "f lI",.hnncl to thp int"nt thnt .hnlll.1 ..i rh"r ,,".han.! nr Wi r" dip.
wi thollt n t~i11, the nther 'pnua", sh(lu 1" thl!Y "t ill h" mardpd, ~hll 11 nnt
!'hare .15 ;In hp.ir :1t lAW undPT intp.9tnt~ RIlCC~n!llin".
2, SEPARATIOR
1 t .ha 11 b,. l"wfu 1 for 1I11.han,1 .,n<l IH f.. nt nil t im"s h.. r"" fte.. to
Ii,VP' Rt'!pflr:atr. :'Inti npt'lrt f..."m Pl1ch nr-hl"r ;"111t1 tn r":caift~ Frnm tiln'" tn t.ime nt
.loch phrr. nr pi 'Ices as thl!Y .h:oll rl!sp"ctlvely <11''''11 fit, fr"" (rom :ony
Interf"rruc.. c1I'rl'ctly or inoir"ctly frnm "nch o~hl'r. Th" .nr"p'"inlt
proviaion shnl1 not be tak..n to h.. no n<lmi..i"n nn th,. part nf ..ither
Illlr:;h:1no or tHf~ of th.... t.,wfnlnrQQ or lInl1wf,lIn"QQ nf t!l"ir livinR :'1pJ1rt.
3. SEPARATION ROT PREDICATED OR DIVORCE
It i. .p..c i fically lIn,ll!rstond :on.1 ngr...,.d by nnrl h"tw""n th.. part I""
her..tn Anrl l!ach nf the .nid pnrti"8 00". h"r..hy wnrr"nt And r'!prp'q"nt t"
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the nth~r. th~t the eKcc"tinn and c1~liv~ry nf thi- ^~r"~m"nt is nnt
prrtllcnr.r.d lIpnn nnr mocll! lIuhj~ct tn .,ny "ll:rr"m,,"t f"r thl! inqtltlltlnn,
rroJllf'!ction. t1efp.nfll~. or for the non-prOAf'!ClItio". or nnn-ctp.fpn,.~ nf .qny
IIrtinn fnr divorce; provided, however, thAt nothin~ contained in this
^ll:rl!~mrnt shall prevent or preclude either of the p~rtles hereto from
cnmm"ncin~, instituting or pros~cutin~ any action or actions lor divorce,
"ith~r "haoll1tl' nr: otherwisl!, upnn .iust, le~II1 "n" proper ll:rOllnrlll; nor to
prevent eithl'r p4r~y from dp.fcnclin~ any such IIctinn which has been, mayor
IIh"ll bc-institut~c1 hy the other party, or frnm makinll: any jUllt or proper
<lcfeMe thcrrtn, Thill Agr..em"nt "hall r~mllin in fllll f"rce "ncl "ffl!ct
r~R.'r,lt~8. or .1"Y chnnJt'! in thfl m."1rit.,l ~t:'ltll" of th,.. p-1rti..,,_
It is
wt1rrrtntl"II, C"nvl'nl1ntprf, llnd rrl'f'!"rnt,....1 hy II II !I: h.,nri .1nn "1i f"', ,soneh to thp
other, tllnt thi~ ^Rre~m~nt is l11Wrul find nnfnr':":'Ihl~ :tntl tl,i~ wl1rr~nty,
cnvt'lnl1nt .1nti rr.J'lrr.~~ntntinn is m.,rlf' fnr tf:1" ~r""ciri~ r11rpn,.,. of inrlncinsz:
It 11 !'I hi'l nfl :lnct t-life to ~XPC"lIt~ th~ ^Rr~f"ml7"nt. 1I11l1;J,nnrl "tnl' Wi ell I'::Ic:h
knnwin~ly nnd undp.rlltAntlinRly hp.rr~y wnivp. nny nn~ nIl pn.~ihlp. ctllim"
th.'t thi." "~r,.rl"pnt j". for nny r,..'~nn, i 11"R.:ll or, ft"r ,'"y rO""f"'n
what.n,.vrr "f p"hlic pnlicy, un"nfnrr""hlr. in whnJ" nr in part. lIuqh"n<l
~n(1 wi. f~ fl"~A (t.'1C"h' hl!t"eby WClTr#lnt. covrnl1nt I1nrt .'1Rr,.p rhllt. in I1ny
pn..lhlp <>vrnt, hI' ,~n<l she is nnd ~h.,11 fnr"v"r h~ ~.tnpp"" fr"m ".q"rtinll:
.'1nv il.lpR.,tit.y nr nn."InfnrcP=1hilitv .,e; "1"1 '111 or :'Iny r~r" .,r th... l\2rp,"Impn:.
It i!ll th... ~p,:.ci fic intt\nt of th,.. (l:1fl"if"1, hn~pvprl th..,,, "hl! tnr",~ "f
thiA ^2r~,..m~nt .,re not !IIuhj{'ct to morlific-.,ti,," hv :'Inv t:nllrt.
T r i_
furrhrr lIn<lpr.tnncl that ppnn"y'vnni,~ 1 nw prnvirl". rhnt "" prnvi .inn "f 'In
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^ltreemp.nt re~,1rtlin~ chit,1 'llpport, vi.it"r.inn nr cu.tndy sh"ll be lIubject
to mndiricntinn by th~ ~nllrt tlpnn n Rhnwina nf rhnn~~~ circllm~t~nCP"II.
4. IIfTKRFERERCE
Elich p"rty IIh"l1 b.. fr"e frllm interfer..nc.., .'"thnrit" IIncl cnntJlct by
the nther, nil fu 11 y as if hp. or she Wl!re II inlll.. .,not "nm.1rri I!rl, I!xc"pt 1111
mny be npce.qnry to carry ~ut thl! pr"vi.illn. nf thin ARrppm"nt. Npither
pnrty shnl1 molest the nther nnr "tt"mpt to ..nrl"nvnr to mnleAt th.. other,
nnr compel the other to cohabit with the other, or in any way harass or
m.~Ii!ln the other, no.r in any WilY intl!rCere with .:,,' F,,:.:;~ful existence,
Al!par"te nnd apart from the other, "nd each of the p"rties hereto
cnmplet..ly "ncll!rst"ncl :tncl "Rr.." th.,r n"irh"r Ah"ll rlo nr ."y nnythinK to
th" rhilrlr"n of the p"rti~q 'It any timp. which mi!lht in any wny influence
th.. rhi Idr'!n mlversely "g:tinst the othp.r p"rty.
5, WIFE'S DEBTS
Wifp. r"pr"qents IIncl w:trrant. tn 1I".hnncl thnr. .inr." thp A"p"ration,
!IIhr. hn!" not nn,1 i.n th~ rlltllrp. ~h'! '...ri 11 not cnntr.,rF: nr inr.llr .1ny dp.bt or
Iin"i Iity r"r which ""."nn,1 "r hi. ...t,.rl" miRhr "l! r".pnnqibl.. nn<l qh"l1
inrl"mniry .,nrl .nvl! hnrmll"'" lIu.h.,nrl frnm '''')7 .,not nIl r.1nimq nr ot"m"nds
m...l.. II~"in.t him by r",'Ann nf r1"ht. nr nhl iRntinno in....'rr"<I hy h..r.
6, HUSBAND'S DEBTS
lltlRh~nrl r~rr~qpntq ~n~ wnrrnnt~ to wir~ tl"r qin~p thp qpr~rntinn. h~
hnq Ill)t /lnd in thp flltt1r~ hp. will nnt, rnntr~("" or incur ""y rf~ht nr
linbility fnr which WiC,. nr hp.r ...tnt,. mi!lht b.. r"'ron.ihl.. IInd .hllll
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inelemnify nncl .ave harmlell~ Wif~ from nny nod nil claims or demnnd. made
IIRAinllt hpr by rl'nllon of "l'hts or nhli~ntin"" incllrr"" h:- him,
7. OUTSTAlmI"G JOIIIT DEBTS
1I1111bllnd shnll provicle documl!ntation to Wife no t" the current status
of the fnllowing debts:
Bill consolidation loan from
bnlance of $4,000.00 II.
Pcp Boys: bi 11
Truck'l~n from Ford Motnr Company
Alexander Rehabilitation Center bill
Kny'r credit card bill
Mobil credit cllrd bill
Pomeroy's credit carcl bill
Agwny b i 11
~'1rli,le 1I0spitlll bill - $4Fi.00 (mrclicnl hill fnr Rrice 6/88)
Dank nf Lanclisburg,
of lIernrntinn
approximllte
Th.. Wife hns paid in full the Exxon and Unitecl Teiephone bill, as
wrll aq the joint vrs~ and Discn...ry accounts, each with balances in
excells nf $700.00 at separation. The Wife shall provide documentation to
IIl1sband as to the current St"tUII of these debts.
All fllrthl!r dehts inclIrrrd hy the pArties shnll 1,.. thrir individual
rl'.p~nsihilit:-. Each p"rty aRrees to inelemnify nn" hnlc1 the other party
hnrmlr., frnm nnrf n~ninllt nny anel "11 ouch debts. liabilities or
ohliRntinnll "f I!v~ry kinel mny nri'l! frnm the "forl!.ni~ hill. and which,
pllr.llnnt to th.. terms her"in, nr.. n"t the rp.p"nsihi I ity nf the othl!r
party.
8. KUTUAL RELEASE
SlIhjpct to thp. proviftinn!ll of thi!' ^~r..,pmrnt. "':11"'11 pnrty hn." Tr.lf'tnsed
and di.chnr~..e1, nn" hy this ARr..em..nt cine, for him.rlf or her,elf and his
nr her heir/I, le~al reprell"ntativell, execlltors, nelmini.trntors Rn<l
5
allsi~nll, rl!lp./l"e /lnd dischnr~p. the othpr nf n,"1 frllm 1111 cllu"es of action,
ct.,imfll, riRht!ll, or dp.manrl~. Wh.1t8o-Vp.r in 1.,,,, or "11"ity. which rithp.r. af
th.. partir~ ~v~r had nr nnw hn" n~/lin"t thl' nther, r~rppt any or 1111
causes of action for termination of the mllrria~p by "ivorce nr annulment
Itnd e~cppt for nny and /Ill c/lu'p.s nf action for brr/lch of any provisions
of this A~reem"nt. lIusband nnd Wifl! IlpeciCicnl1y rplpn~c nnd waive any
nn" 011 ri~ht he nr she mi~ht hqvp' to raillr claim.. undrr thp. Divorce Cncl"
of 1980, all oml'nde-ll, inc1udin~, but not limitl!d to, ctaimll fnr p.quitllb1e
c1lstribll~io" nf m'lritnl property, as well all "prciricnlly any Intprest nf
any kind he ~ny have had in the property at 122Fi Clnremnnt Rnacl, Carlisle,
Peunllylv'lnia, nwned by Wifl"s parent".
9. DIVISIOR OF PERSORAL PROPERTY
Alt furniture and furnillhln~s pr,,"ently in t.hp pn..rllsinn nf Iluqband
and of Wife, individunlly, shnll rrmnin thrir separnrn prnp"rty oncl paeh
h"rp.by tran"fer. to the othpr any ri~ht, title an" intl'rnllt he or shp. may
hnvp in the furniture and furnishing~ pr..scntly in the possession of the
"rhpr, p~cept for the following items:
Wife ..hall return to Ilushan":
OR~ ~leetvie ~tnAltvt
"...- et~81t F1~i~
,,~- Gr~rl'p<1t l
Rr"rcat pr"ltrnmnonhlc "cnnnpr~17
~~=:-:~;i:;';'i ,~~:rJ ~
n'lr weddin~ bnnd
F.n~agpment rinlt b
Anniversnry rin~
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lIusbnncl hereby w'Iives all intp.rest in Wife'lI propp.rty incluclin~ but
not limitrti tn 1111 Account.... W;f~ h.1J11 no rrtirpm"'nt hrnpfit!l'.
Wi CO! hereby waives all intp.r"9t in lIuqhand'" rroperty inclllding but
not limited to all accountA, cp.rtificlltp.s of c1epn.it, ancl securities,
includin~ Capital Prodllcts Stocks and Carlisle Tirl! nnel Rubber retirement
benefits. The lIusband agrep.s to lIiRn AKC r"Ri.tration pnpers titlin~ the
p.~rti",,' AKC rr.gis.tered dOR, !>adip. Amber, IInd .,ny p"ppie" from her litter
whelped in AURust-1989 to the Wife,
10, "OTOR VEHICLES
With respect t~ the motor vehicle" owned by nne or both nf the
pnrti"A, they agree all follows:
(a) The 1986 Ford R~nl1;"r pr..""ntly jn;ntly titl..el, ..hall bl!come
anrl remain the sole .,nd exclusivr. property oC thp Iluqhnntl, This vehicle
is security for a Inan with Forcl Motor Company, and lIl1shnnd nl1;rees to
inclemnif, and hold hnrmlp.ss the Wife frnm nny all linbility for this debt,
(b) The 1964 Doel~.. Charger pres"ntl, titlp.r1 tn the Wife, shall
become and remain the 1I01e and "xclulliv.. property nf th" Wife. It is
sl!curity for a loan at LnY9ville Rank, an" Wif.. "I1;r....1I to indcmnify and
h~lc1 harmless the'Hushllnd from any an" all liability Cnr thi9 "ebt.
11. WAIVEll OF RICBTS U1mEll THE DIVORCE CODE, AS AIIERDED
lI"sb'lnd and Wife specifically relealle and "'.l1VI? any and all right he
or she mi~ht have to raise claims under the Divorce Cod.. of 1960, as
ampndecl, inc1urlinR, but nnt limit",c1 tn, c1nims for e,\uitable c1istribution
nC marital propr.rty, and indemnify and hold harml"ss the other from any
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lIuch c11t im. Shou Id a divorce Ite t ion he commp.ncp.e1 by ..i the r of the
Pllrtie", the mnvinj! party "hAll rp.'l',eqt thl! COllrt tn inellrpnrnt.. this
Al!r.."ml!nt intn It Divorc.. Decrl!e. If thi" ^~rcpm"nt i. inc"rpnrated into It
Oivorce Decree, the pArties shall hnve the ril!bt tn enforce this A~reemp.nt
undl'r thl! Oivorce Code of 1960, a" Am"ndl!d, in ndditinn tn Any rempclip.s in
law nr I!qllity, nnd th..se enforcement ri~hts nr.. nnt wqivp" nr rl!l..nsed by
nny of th.. prnvis~onll of thill Agr....ml!nt. TI1P. fAe~ thnt ., pnrty bring" Rn
, --
action to enforce--the propp.rty A~reem..nt aq incorpnrRt..d in the Divorce
Oecree, ...nder the Divorcl! Cocl.. of 1980, ,'8 nml!nded, fInes n"t givp. I!ither
pnrty the right to raise other clAims uncler the Divorce Cnde, specifically
w.,ived nn,1 rele'l"ed by this parn;trnph, "nd nIl ri~hr. nn.t nh1 il!ntions of
thp. I'nrtip.~ nri..inR nut thp. mi1rri.,~~ !l'h.,11 hp rf,.r"rmin,..d hy thi..
Agrt'emen t.
12. CUSTODY
1I11l1ban" nnd Wife a~r.... that they "hnll nhArp i"int le~Al clI"tocly of
th,. pnrti..s' millor childr..n. n",dnnin;l; ^'I~lI"t 2S, ICl~Cl, nn every nther
Fridny, wh..n the nUllbnnd workll dnyq, he "hnll hnv~ pArtin1 cURtody of thl'
Children nnd shnl1 pick them lip After hill IIhift nn Frlclny; whpn he workll
"l!cnnd "hlft. ilfter wnrk con S.'tHr,I'IY; whl'n h" 'mrk" third IIhift, on FriclAY
nt ]:00 p.m.; nnd he IIhall rl!tllrn thl! Chll<lrpn t" th" mnthl!r nt Fi:OO p,m.
on ~lInct.,y in :'111 inst;lncp~.
Ourin~ thp wep.k th.. f.ther hns the Chil<lren nn thp. w-ek..nd, he "hnl1
hnve partinl custody of the Childr-n on.. pvenin~ per wepk frcom th.. pncl nf
his IIhift until 9:00 p.m.: the week the father doell not have the Children
8
nn the wepkend, hp. shall hnve p3rtial custody of th.. Children two (2)
t'vt'ninp." rp.r w....k frnm thp. ..nil "f hi" qhift until 9:00 p.m. Thf' fathp.r
n~rp.ell tn pr"nrrnn~p. the "I! c1ny. with the mother fnrty-pi~ht (46) hours in
ndvnnc... It ill underlltond thpse timps 3re not to cnnflict with pre-school
pro~r'lms or nth..r scheclulell nctiviti,," nf the Childrp.n. Th.. mnther nsrp.es
to infnrm the fnther timp.ly nf such prn~rnms or nctivitip'1I nil they nrp.
"ch"du lell.
. -
The f3thf'r nRrees to inrorm the mnthp.r in n tim..ly mnnnl'r if he will
be delny..~ in pickin~ up or droppin~ o(f thp Chilrlr..n. rf hp. iq mnre thlln
nnl!-hnlC (l/2) h"ur late in pickin~ up the ChUrlr.." .,nrl hns nnt clll tecl the
mnthp.r, thnt visit will hp. cancelled.
The f.,thpt'" i~ tn hnvf"! J1:1rt L"ll CIIRtCHiy for f'nr t.I"rk roAch y"nr nnct iq
to providp. the mother three ()) wp.ek. n<lvnnc.. n~tir.e nf th.. elate. lIelected
by him. DurinR this rim"', the mnth'!r l'Ih.11 I hnv~ r.1I"tnrly onr. cvp.ninR from
rh.. "ncl nf hp.r wnrkllny until 9:00 p.m. This "vp'"in~ ~hnl1 h.. qchpdule" lit
rh" tim.. the father provide. her "otic.. nf the dntp. nr hi. wp.ek-lon~
vi~it.
The wir.. .hnll ~ivp. thr".. w....k" nntic.. n[ h..r ;nt"ntinn to rnke the
Chilcfrpn on v:JC'Atinn if ~.,id v.1cation rfiqrllptQ ntl~h.'n(t'q visitntion
"..h..lllll" ,
E.,ch I".,rf"'nt !l;hnll h:1V~ tel~rh('\n(" ronl".1ct ..-ith th,.. r.hil.fn.n nn~p. per
",pek whp.n rhp Ch i Illr..n .1t'P wi th rhp. nthp.r pnrpnt.
Wif.. n~reell to HlI"hand hnvins ndclitinnnl, ren.nn'lhl.. IInd libernl
tp.mpornry phy" ical Cll. tocly fnr purposes or vi. i tn t i nn nil thp pnrt i..lI mllY
q
., -.
n~rl!e from time to tim~, prnvided HlIshnnd notifir. Wifp. fnrtY-l'i~ht (48)
hourI' in nrfvnncp._
13, CHILD SUPPORT
lIl1sbnnd agrees to pay $415.00 p~r month chi' I ~u~~'rt until Harch 31,
1990, designated as $275.00 as the current child support amount and
$11,1).01) n" pnym..nt townrd nrr""ra~..s lint i 1 th~ nrrenrll~p.II are pa id in fu 11
nr March 31,
1990; whichpver nccurs first, and $275.1)0 per month
. --
.-~
lIpon the c1ate of the final Decree in Divorce, the entire
thl!renft..r,
nmnunt ""n11 be allocated 811 child ""pport,
In the event there ar.. nny It'.ppnrt lIrrearn~r" du". th" lIl1nb..nd agreeS
to p"y the Wif.. "n ndditinnnl $115.00 rr.r mnnth IIntil ouch timl! all
.1rr"'~rnp."'s tire rp.p;1id. This i" tOW'.1rrf r.hi lei lltuf'pnrt :trr""r"R-~.
14. WAIVER OF SPOUSAL SUPPORT, ALJKOIfT P!fl1)!wn: LITE, AJID ALIMORY
Thr pnrti..1I herein ncknowll'dRe thnt by rhi" ARrrrmrnt th~y hnvp ..lIch
rp"pl'ctively sl'cured nnd m..intnin"c1 " ,,"hstnntinl nnd nrl.~lInt" fund with
which to provide themselvl's and rhr Children who mnv live with them,
!lufficirllt Cinnncinl r~~OllrCP!l tn Jlrovirlr. fnr th...ir c<"lT1fnrt, mtlintpnAnCfI
nnd ""pport, in the ntntinn nf lifl! in whirh thp, nr" nccuntnmecl. Wife
nnd lIullband dn her'ehy wnive, relen"e nnd Rivl! lip an)' riRht" they may
rl!spectively have a~ainllt the oth..r fnr nlimnn,. nlimnny p..ndp.ntp lite,
~urpnrt or mnintrnnnc~. Tt ~h~tl hr frnm tll'" ~:ttr nf tlliq ^2r~...m~nt th~
"nle r~spnn"ibility of ench of the renpectiv~ pnrti,," to ""otnin
thl!mselves without seeking any 9l1pport from the nthr.r p..rty.
10
'.
15. MEDICAL IRSUlW'ICIl
Hu.hllncl wi 11 cnntin..e to provicl" mp.r1 iClll in,olr.'o~p cnvp.rnl!p. fnr the
Chi Idrr.n and the Wife as 10njl nil hI! h". any c1llty of ."pp"rt tn them, The
Wifp. will PllY all uninsured meelical, c1entnl, optical nr prescription
COllts, including the inllurance dp.ductihll!, IInrl .hp. .hllll he solely
entitled to receive any and all in.urllnc.. reimbllr.pmrnts IIncl Major Meclical
inllllrnnCp. refunds ~hereon.
, --
The Wife agrees to provide the HURbllnrl with hills or statements for
filing with the insurance carrier in a timely manner, The Huaband agree.
to turn nv"r nil insurance proce..e1. IIncl Hlljar Hedir.'11 insllr'lnce refund
chp.ck. to WiCe within fiv.. (5) dRYS nf his receipt of .ame.
lIu.hanrl njlrces to pravirle Wif" all necell..ry oumbcrq. cllrds and forms
neces.ary to carry out thl! intent nf the above pnr.l!rllphs.
lIullband agrees to pay on..-half (1/2) .af IIny ":<trllnr<linnry medical
exp..nsl! far the Children not covered by insurancp, ind...ling cnst for
orthndnnt..re, if n"cess,ny, The dpcilli"n to inc..r .."tr,,,rclinary medical
""pl!nlles IIhal1 be n joint one, and lIu.bnnd nl!r...q ont tn withholc1 his
conRr.nt for IIny ~uch exppnnC!l; wh ich wn'11rl hE>> r".'~on:1h I y "r.cP~~lIry.
16. LIFE IRSURAftCr:
The pnrties Wllrrllnt and rpprF.cnt thnt thpy .hnll namp. th.. Children
.,~ irrevncnhtp banp.fici.qri~~ fnr .1!IJ 11'\nJ! .,q throy h!1vt'" .'1 dllty of ~Urp(\rt,
nn the pnlicil!s of insurllnce nn thl!ir liv". a. rprr".p.nt"d by thp. nttached
1illting incluelt'c1 on Appendix nAn Iluachl!c1 hl!rp.to nnd made n pllrt hereof.
Each party warrants that they have not mnelp. nnd will not make any 10'lns or
11
"
.
,
~,"illnmcnts uncll!r such policies, ,~ncl will l1"t c"ncrl nr ~lIrrendp.r sllch
policies. Upon the other'lI re~\In.t. ..ith..r p,nty .h"ll nx..Clltl! any
documl!nt npcellRnry to effect a conVl!rSilln or .~Icct an option IInclr.r any
RlIch pol icy. Roth parti,.s agree tll make pnym~nt of premiums on the
policiea on their inclividllsl 1iv~s 110 as to continlll! R.~icl covp.ralle as long
all the Children are oweel a dllty of IIl1pport.
17, LEGAL COUWSEL
-~
Husband i.. r/!'pr...entl!d by thl! l11w office of 1l0LHAN & 1l0LHhN, and wife
is repr.....entl!d by Ruby D. Wel!ks, F:sqll i rl!, nn.1 ench nr th" pltrt ies agree
that they have entered into this ^llr"ement with n cnmplete unclerstsnding
of the contr.nt. thereof and after complete di"closurc nf nIl nssets,
liabilities and rights that they each may have,
18. ATIOR1IE1' FEES. COSTS & EXPEWSES
The rnrties s~ree to waive receipt of and to be responsible for their
own nttorn~y fe~A. costs and ~xpen~r.~.
19, EHFORCEKERT
If "ith~r rarty brl!nchnR nny pr"visinn nf this ^grrement, the Dthp.r
party ahall hnve th~ right, nt hi. nr hnr ,.lpctinn, tD .ue for d~mn~e" for
Rllch brench or to :lIeek other remerl i"R nr rpl i"r o. m"y be nvni !nhle to him
nr her, nncl thn p,uty brl!IIchinl! thiR Allre"ml""t ahnl t b.. r""pnnaibll' for
rnyment "r rp.,ann"hle lpp.nl fpPR .,,,r1 cnRt. inc'lrr"" hy the nther in
~nforcin~ hi~ or h~r ri~ht~ 'lnd~r tlli~ ^Rrc~m~nt. Fnilllr~ to ~eek a
r..medy fnr Dnp. or more br..achr.1I shnll not he c1el'm..d a wniver of any
.ubse~ul'nt hreach.
12
"
,
,
20, ADDITIONAL IRSTRUKEWTS
F.Ilch of the partie. shall from timp. tn tim", at th'! r'!'l"ellt of thl!
other, expcute, Ilcknnwlerl~e, Ilnd rlp.liver to the othpr party IIny ancl all
further inlltruments that may be reallonahly rl!'luirccl tn ~ive full f"rce anrl
effect to thr. prnvision. of this AKreem..nt.
~
21. APPLICABLE LAW
--
Thill ^Kreeme;t sholl be construed unrlpr thp. IllWIl of th.. Cnmmonwealth
of Pennsylvania.
22, VOID CLAUSES
rf any term, clalllle, cnnrlition or provisinn shall hl' r1l!termined or
rlcclAr~(1 to hr void or invnlirl in In~ nr n~llrrwi~r. th~n nnly thnt tprm.
clause, conclition or prnvision "hall b'! IItrickr.n fr~ this ^~reement anrl
in all other rp.llpect this Agrp.ement IIhall .be Villi" n"rl continup in full
fnrce, ..ffect Ilnd operAtion.
23, BIRDIRG EFFECT
Thi. Agreement shall be binclin~ Ur"" the rp."""dv,, PArties, their
heirs. r.x~cutorsJ administrators. succ~ssor9 and n1~igns.
,
24, DESCRIPTIVE HEADINGS
The c1e"cri pt i ve hp,,<t ingq UllCrl hpre in Are fnr cl"nv..nience only, They
'''nIl hllVp. no "ffp.ct wh.'t"or.v..r in "ptl'rmininst th" ri~ht. or ob1i~ations
of th" partic".
13
"
.
,
,
,
25. ERTIRE ACRE!HI!IfT
This ^o:r..~m..nt conto'lins thp. ..ntirr llncl..r.tnnrlinp' of ~h.. rnrties and
thrrr nre no rppreA~nt~tion~, covpnnnt~ nr I.nff~rt~kirl~~ nthpr tllnn tho~e
..xpr"s"ly lI~t forth her~in.
TN WITNESS WHEREOF, the parties hAve herellntn lI..t th..ir hllncls And
~.?;;~'
IIbDve uri tt..n.
..,
,
14
APPBlOJII "A"
LIFE INSURANCE POLICIES - PARAGRAPH 16
Policiea on the Huaband:
Company:
Policy Number:
Amount:
Beneficiariea:
--
. .=,.,
-
.-..; .
Policiea on the.Wife:
Company:
Policy Number:
Amount:
Beneficiaries :
:
-.-
Aetna
2626-11
$26,000,00
~ale Cendall Bridge
Brice Elliott Bridge
~
KILICO
0420549014
$100,000,00
~ale Cendall Bridge
Brice Elliott Bridge
If children are minora-then to Doria
R, Weibley in Trust for children
.
<
~
.
r.o'rnONWEAL~OF PENNSYLVANIA
COUNTY OF ~lJ
!liB
On this, the.3/$ day nftJ/'ht~~___, lQff, b..fnrl'! me, a
N"tary Public, the uncll'!rlligned Qfficer, p..rq"nally nprearecl JODY L.
IIR CDGE, known to mp. to bp. thp. rp.r.nn wholll! naml'! is s"h~cri hpcl to the
wi thin Propl!rty S<;..tt lem..nt Agrl!em"nt, and ncknnwl adctpd thAt hp. ..xp.cuted
the ''1ml'! for the.~rpo.". .th..rein contnin..c1.
"
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c:AntIIMI c:. . .._ 1KJIDUIr".ec
CIrraI..... ...., CIIInIr '.,....., ;
Com. 'II' - ..... to. ItI2
r.OHHONWF.ALTn OF PENNSYLVANIA
:
ss
cnllNTY OF CUMRF.RLAIlD
On th i q. th" l.4-1+. d"y"f ~~a:!hbc__. I q '19, hpfnr.. m", ..
Nntnr, 1',,111 ir., thl! lInrl"rQlltnpd f\ffir~.. r"r",.,.,llv ,'rr"n.p<l DEBORAII W.
rmfl'lr:F.t known tn ml" to hI' thl! l""r~"'11 Whf.'~" n."1r.'l" ic; qlth!ll:r;rih~ti to th,.
within I"rnp...rty ~"ttl",,",.nt ^Jtrrpm""or. :Inri nck"'''<lI''.ht",1 thAt Ahf' P.ltt-clIt"cf
-.-
th,. I\.1mr. fnr th'! ptlrrO!;~lI thrrf"l in C"n"t.' inrll.
._21h~.,.4:_0~.
Nntnry P"hl i. "
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NOTARIAL SEAL
SHARON A. DIEHL, NOTARY PUBLIC :.
CARUSLE BOflO, CUMa~illANO COUNTY''..'' " . ';,1
MY COMMISSION EXPIRES FEBRUARY 22. 1883- /18
.
15
.
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a.
.
JODY L, BRIDGE, , IN THE COURT OF COMMON PLEAS OF
.
Plaintiff , CUMBERLAND COUNTY, PENNSYLVANIA
,
vs, CIVIL ACTION - LAW
DEBORAH W. BRIDGE, , NO, Q4--,:)'3 4-7 Cu~ -r~
,
Defendant , IN CUSTODY
,
AND NOW, M'" ~
attached Complaint,
ORDER OP COURT
\{\ , 1994, upon consideration of
it is hereby directed that the parties
the
and
their respective counsel appear before Hubert X, Gilroy, Esquire,
the conciliator, at the 4th floor, Cumberland county Courthouse,
on \;:::j \ (~f ' thel ~f day of T~\ (y , 1994 at to,./) ,m., for
a Pre-Hearing CUstody Conference, At such conference, an effort
will be made to resolve the issue in dispute; or if this cannot
be accomplished, to define and narrow the issues to be heard by
the court, and to enter into a Temporary Order. All children age
five and older may also be present at the conference, Failure to
appear at the conference may provide grounds for entry of a
Temporary or Permanent Order,
BY THE COURT,
-zjl?-~ t. "
:::;.-: <'
"X(
~/'
BY:
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE, IF YOU
HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE
SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
DO NOT
OFFICE
Office of the Court Administrator
Courthouse, 4th Floor
CarliSle, PA 17013
(717) 240-6200
1
._-,."",~
H:.r /9 J 4/ ;'ij '9~
, ".1.\
'I : :'f
; ..
...........--.......'
vs,
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
94, ,) 3Li 7 r: / ~'I I Tu('{)
NO,
IN CUSTODY
JODY L, BRIDGE,
Plaintiff
DEBORAH W, BRIDGE,
Defendant
PETITION POR MODIPICATION OP CU8TODY
AND NOW comes Plaintiff, Jody Lynn Bridge, by and through
his counsel of record, Barbara J, Yunis, Esquire, and petitions
the Court as follows:
1. Your Petitioner is the above named Plaintiff, an adult
individual currently residing at P,O, Box 352, 5 Front Street,
Boiling springs, CUmberland County, Pennsylvania,
2. Your Respondent is the above named Defendant, an adult
individual whose address is 1226 Claremont Road, Carlisle,
Cumberland County, Pennsylvania,
3, The parties are subject to a custody Agreement which is
referred to in Paragraph 12 of the Property Settlement Agreement,
effective November 6, 1989, a copy of which is attached hereto
and incorporated herein by reference as Exhibit "A", relative to
the custody of their children, namely: Kale Cendall Bridge, born
April 7, 1986 and Brice Elliott Bridge, born September 2l, 1987,
4. Respondent has had primary physical custody of the
children since the parties' divorce in 1989,
5, The Petitioner has had partial physical custody of the
children two nights a week during the week Petitioner does not
have the children on the weekend and one night a week during the
week Petitioner has the children on the weekend,
2
fiance,
presence
occasions;
6, It is believed and, therefore, averred that
interests of the children is to be in their father's
custody for the following reasons:
(A) Since the parties' divorce in 1989, Respondent has
had a history of residing with various boyfriends who have been
abusive and/or associated with drugs;
(B) Respondent has resided for the past year with
Milton Stackfield, who has assaulted Respondent in
of the children, as well as, on numerous
the be.t
physical
her
the
other
four
(C)
incidents
The Middlesex Police Department has responded to
in the last four months regarding domestic
violence at Respondent's home;
CD) The violence at Respondent's home is very disruptive on
the children's lives,
(E) On at least one occasion, Respondent
taken to the hospital to be treated for her injuries
Mr, Stackfield;
has been
caused by
(F) Petitioner believes these conditions are very
stressful for the children and fears for the children's safety;
(G) Despite the violence, Respondent has continued to
allow Mr, Stackfield to reside with the children at her
residence;
(H) Respondent allows her fiance, who has been
arrested for selling drugs and is believed to frequently use
drugs, to continue to reside in the residence with the children;
J
(I) Petitioner believes Respondent's fiance is not a
proper role model for the children and that the children are
adversely affected by individuals such as Mr, stackfield, who
Respondent repeatedly allows to reside with her and the children;
(J)
It is believed, at the present, that
Mr,
Stackfield is serving time in the Cumberland County Jail,
However, if his bail is posted, Petitioner believes Respondent
will allow Mr, Stackfield to return to her home as she has done
repeatedly over the years,
(K)
Petitioner is fearful the children will
be
physically and mentally harmed if they continue to reside with
Respondent;
(L) Respondent has routinely been unemployed.
eM) Petitioner has been gainfully employed for the
past six years and has remarried; and
eN) Petitioner is better able to properly care and
provide a stable, loving environment for the children,
WHEREFORE, Petitioner requests your Honorable Court to
modify the Agreement of November 6, 1989, and provide for
Petitioner to have primary physical custody of the parties'
children,
Respectfully submitted,
GRIFFIE & ASSOCIATES
./J I'
BY lcJ....C lU4. I, 't;.U:f
Barbara J(. s, Esquire
200 North Hanover Street
Carlisle, PA 17013
(717) 243-5551
4
I verify that the statements made in the foregoing document
are true and correct, I understand that false statements herein
are made subject to the penalties of 18 Pa,C,S, Section 4904,
relating to unsworn falsification to authorities,
DATE: -;-6/9'1
~~/ ~~~.{~
rDY B~I ~
-::...-.,
.. .
.. . "
.. , :;
.. " ..
.
.
PROpaR1:Y S!Tr1.l'.H1<JlT AGilF.IlKP:1fT
THrs Ac:R":f.";::m-, rJqt,,! rhp . I.P~ ,In:' ,.r _!{Q'i~ 1 'lji., hy IIn"
bl!t'''!l!11 .lOD'l LYNN ilRmCl';, redcling "t R,O, 'II, ilox "86, Shermans Dale,
i"..rry r.~..nty, .Penn~ylv"ni", S"cilll S,.o::nrity Nu..'" !n&_<Fi-7256,
lIr.rpinnCt'!r called thp. "Hushand", anel DEBORAH W. IIRIDr.E, f"rmerly WEIBLEY,
rl!qiclin~ nt 122" Clarl'mont Rond, C'Irttsl~, ~Imhprlnn<l County,
PennllylvnniA, SQc;t'l1 Security Number 196-48-2679. h..reinafter called the
'-1
"Wife". "'ho .q$t~P.'! as f,,11ows:
WIT ~ E r. S F. T H :
~IIEI\F.^S, the rartil" Are nnsllnncl nnel Wif.., 1.,'1in~ h"(o1l m'lrdl!'\ nn
\\
g"ptlllmbl'r 1.9. 198/.. in St"~r"';U'UI n.'d,., r"'~r1 r...,nnP'.,. r"'nn~...~v'ni:t.. Th,.
rnrti"" "~rnrnt..d Jul, 15, I~A~.
WlffiRRA~. t~~r~ hnv~ h~~n i~~'I~ ~f th~ m~~ri~~,... tn ~~:: K^r~ CEND^~t
ilK rOGE, horn ~,pri 1 7, 1 ?ilFi, one! RRT C7. F:I,I'-Inrr Poll Iil!:r:, hnrn g"rt"mb<!r 21,
1087. h~rqinnft~r r~ferTPft to ~~ til~ rhii~ren.
WflF.'U:^~. nl,o;h.,nrl nnd ~;/;rf'" .,rlll .I"'c:iro,II' ('If "',",virli.,~ f"r r-h,.
cfi~pn..iti"'n ('If :'111 tlll"\i 1I~~~tA in (.ont:--m('ll:tt i'l" ('If r"'rmin:1~inp' thpir
mnrri.'RP; :,":-1
UH~RF.t\S!, Itu'lhancl :Inri tlifl! hnvp. m."ull! n rnmrlaotQ .fi~clnA'''.p. to r-.'l~h
.,:-hnr .""If ,11 n~c;~t.q thnt t'h~y hntrl "irl'roT in.li'li("I,I~'1 (\r .,n inior: tQn.:1nt;'~'
wir.lI ("'eI: :'\1 h,',- ~1,,1 "nth p.'rr:i(lo~ 'c..~..,w1"'tf!':"" th,t rh...~' ",.,.... I;."\ff :t:'l
"'''l:-'I''.rt'qn~ty t., go .....1i''!r ':~l~ rflqr:~'.'~Hl-.'" l..'it"~i .," '~"I~r""'.~ '1nd
N(H~, ':'II!~~r.~0Rr.. 7!f~!~ '.r:~"~F.~IF.NT ~.;r.:':r:-::.~~Ff'n rh,t r'1r ,,,,,,1 i"
conq ic1r.rnt. i f':n of th,.. pr,,!"!i!;t:t~ :"n,1 cn.'....r.:1ntq h,"',"~;" r.llnt.'~ "",i :1n.1 i nt':'nrtin~
EXHIBIT "A"
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tn bp. l~glllly bound hereby, it is agreed by and b~twe~n the parties hereto
"s f 0 1l0w~:
I. WAIVER OF CLAIMS ACAUIST ESTATE
lIusbllnd hercby w:lives hi. rillht of election to take against the Will
nf Wif~ IInd Wife hereby waive" hpr right to take agllinllt the Will of
HII~hnncl: snicl wlliver of right to nlect ill macl~ In accorclllncp with thp.
Prohlltp., Elltlltl!a IIncl Fi""ciariell Cocle, Act nf 1972, Junl! 30, P.L, 508, Ro.
IFito, 20 PII. C.!l.A':-12207.
Shn..lll ,.i th..r Ilushnnd nr Wi ft' "i" w; tho"t n wi II, n".hnnd hpr"b,
wniv~s the ri~ht, title nnd intp.rpqt h.. millht hnvn in th~ Clltnte of Wife
:In" Wife herchy wnivcII the riRht, tit!,. nnd int~r,..t .hl! mi~ht hllve in the
".tnt" "r lI"sh.,"d to th.. intpnt thnt Aho"l<1 ~ith"r 1I,,~hnn" nr Wifn "ie
without nIHIl, thl! other IIpnU~l!, ~h"ulrl thl!Y .till hI' mnrril',I, ,,1,,111 nnt
!IIhare .'19 .tin hr.ir :'It l:1W und"r int~9tl1tP. A'~cc"!IC!lIi()".
2, SEPARATIOR
It shll1t h,. l"wful for 1I".hnn,1 "nrl tHf.. nt '111 tim..s h"r"..fter tn
liv~ 9~pnrntr nn~ nrnrt rrnm p~ch otll~r ~'lll tn r~~i,l~ from tim~ tn time ~t
'"eh pll\~c nr pll1cps as they shnl1 rp.sp..ctlvp.ly ri"pm fit, rr.... fr"m nn,
intcrf..r,,"c.. c1irl'ctly or inriirrctly frnm ",1ch othnr. Thr fnrpp'nln~
pr"vi~lnn .hlll1 not be tak..n to h" nn ndmi'Ai..n nn th.. pllrt nC ..ither
Hlt~h.'nci nr tlif~ of th."'l t.,wfulnr!'lQ or II"l~wrtlln"qq ('If thf:'ir livinR !'fl'lIrt.
J. SEPARATIOR ROT PREDICATED OR DIVORCE
It is sr"c i flc'll1y lIn,ll!rstnod nn,1 nRr"p<l by ~",I ""t"'''''n th" l''1rtl...
h..r..t" and l!ach nf th.. Ani" rnrti,.s ri",," hnr"hy wnrrnnt ancl rnrrnqpnt to
2
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" .,
the nth..r, th'lt the l!xecllt ion nncl c1t' Ii v"ry n f th i. ARr....m..nt is n"t
rr"<licnt.l!d lIpnn nnr mncll! lIubjpct tn .,ny nRr...."".nt f"r thl! inot.itlltinn,
rroRp.ction, rlcfenRlI!, or for the non-prOAncllt ion, or nnn-defllnA4" nf "'"Y
'1rtinn fnr divorce; provided, however, that nothing contained in this
^Rrep.mpnt shall prevent or preclude either of the p4rtles hereto from
cnmm..ncin~, instituting or prosl!cutinR any action or actions for divorce,
..ithpr ahaoll1te o~ otherwise, uron Just, le~nl nnd proper ~roun~s; nor to
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rrevent "ithl'r r~r~y from d..fendin~ IIny such act inn which has been, mayor
IIhnll bc-institut..c1 by the other party, or from mnkin~ any just or proper
<lefenae ther..tn, This Agr..empnt .hall rpmoin in ~ll1 force oncl "ffl!ct
reR,'r.ll"as nC "ny chonge in the m.,rit,,1 stnt". nr thr p'Irti..q. Tt is
wnrr:1nt,.,I. c-"vI'n"ntP,f. nnd rp"r,!,~,.."tp.1 hy IIt1J11lh:tntf .,ntf Wi e.... IlI:wrh t.n th..
other, tll~t thi~ ^Rre~m~nt is Inwrul find ~nFnr~"nh',.. :'Incl tl,i~ wnrr",nty.
co'/,..nllnt .,nr! rr.prr.nC"ntntinn is m:"i,.. for r:l,1p ~rpciri'" rnrpt'l'" nf ;ntfllcina:
I1l1!l1h:lnll :and t-li fc to ~)(P(,"lIt'!' th'! ^arapmt:"nt. nnqhn",1 '"f' Wi f,. f't~C'h
knowinRly and underllt'lnelinRly hf!rl!~y wnivf! any nn~ ,11 pn~.iht.. ctnimq
th.,c thi."C ^Rrp"'mpnt i~, for nny r..'~nn. i11t-st.,. nr. r,..r ,'"y r~:t"t"n
whntso"v..r "r Pllhlic r"Ucy, un"nfnrrrnhle in whnt.. or in rart. lI"qhand
~n(1 Wifp ,Io~~ pn~~ h~reby warr~nt. cnvrnnnt "n~ ~~rpp thnt, in nny
pn..ihle "v..nt, hr. nnrl she is nnd .h,,11 fnrnvpr hn n.t"rr..<l from ".."rtinR
.,nv ilLpp..,l ity nr I1nt'''nfnrcPl1hi lity :'1-: tn ,11 nr ,'"y r."rt .,r th... !'\strf"l,..",pnt.
It i!ll th... ~ppcific intl"nt or th,... p"r"if>'I, hn'J,.vnf, th..,,, thl! t~rm" "f
thi~ ^Rr~""mE'nt .,re not lIIuhjrct tn rnntlifir.,ti"n hy .,nv Cnllrt.
T r i.
rurthp.r "n<l....tood thAt P..nn~ylvnni., 1.,w prnvi<ln. rh"t "n prnvi.inn nf An
,
, .
.,
^ltreemp.nt rp.~:Jrdin~ chUrl ,urport, vi~itnt.inn or clI~tndy sh..ll be 8ubject
tll mndiriclltinn by thp. C:nllrt urnn 11 IIhnwinll nf rhnnp,,,rI circllmqtl1ncl'II".
4, IRTERn:RERCE
Elich pltrty IIhl111 bp. frre frnm interferrncp., .'"thnrity, ..ncl cnntllct by
th~ nther, 118 fu 11 y as if hI! or she Wl!re II inlll.. nnrl unm.1rri p.rI, p.XCp.rt 1111
m.,y be nr.ceq~.'ry to carry "lit th.. pr"visinns nf this ^~rp..","nt. Neithp.r
pnrty shnl1 molp'"t the nther nnr ..tt-mpt to r.nrl"nv"r to mnl'!..t th~ other,
n"r compel the other to cohabit with the other, or in any way harass or
m.,liJl:n the other, no.r in any WilY intl!rCere with ':,.' Fo::,~:dul existence,
ol!parate I1nd apart from the other, and each of the p'lrties hereto
c"mrletp.ly uncll!rst'lncl '1ncl "llr.." th..t nrith_r ..h..II riD nr o"y "nythinR to
rhr rhil<lr"n nf t.h'! p..rti"q ..t ..ny time which miJl:ht in any wny influence
th.. rhildrp.n 11,lvt'rsely 'lj:..in8t the othp.r p..rty,
5, WIn's DEBTS
Wifp. rPrr..s'!nts ..ncl w..rrantll tn 1Il1.hnn<l thnt. qin~" thp ""rllration,
~h~ h,,~ nor :tn" i." th~ r'1tllt'P. ~h~ '",i 11 not cnnt"r.,rr: or inr.IIT .1ny dp.ht or
linbility fnr which lIu.h.,nll nr hi. P.r..,t" millht h.. r"'rnnqibl- nnrl ..h..l1
inrl"mni fy nn,1 '"VP. hnrml"ss IIush.,nrl from "nl' .,nrl nIl dnimq nr c1..m.,ndll
mnrlp ..~,inst him by r"nson nf r1..ht. nr nhliltntinn. in~lIrrr.<I by h~r.
6. RUSIlARD'S DEBTS
'"IAh.,"rI r"rr",qpntq .,nrl wllrr.'nt~ tn Wi r~ th'U" __int:'n thp tI"'""rnt;nn, hI'!
hnq n"t .:1",1 in thp flltllr~ hp wi 11 n.": ("'nntr~("" "r inclIr .1"Y rtt;tht nr
linbility fnr which Wif~ nr hl!r ..st,t" mi2ht b- r""pnn.ihlp IInd qhllll
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indemnify nnd .ave harmlells Wife from 'my nnd "11 claim~ or demnndll made
nRninllt h"r by rl'nllon of dphts or nbli~ntionll inclIrr..d by him.
7. OUTSTARDIJIlG JOIRT DEBTS
nllllbnnd shnll provide docllmp.ntation to Wife n. to the current status
of thp. fnllowing debts:
Bill consolidation loan from
bnlance of $4,000.00 n~
Pcp Boys: bi 11
Truck 'l~n from Ford Hotnr Company
Alexande1r Rehnbilitation Center bill
Kny'r credit card bi 11
Hobil credit cnrd bill
Pomeroy's credit cnrd bill
Agwny bill
Cnrlillle 1I0spit'll bill - $4Fi.OO (m..c1lcnl hill fnr IIrice 6/88)
Dank of Landisburg,
of sepnrntinn
approximllte
Thr. Wife h'ls pnid in full the Exxon and Unitecl Teiephone bill, as
w..ll n. the joint VIS~ nnd Discnwpry nccountll, e'lch with balances in
excp.~s nf $700.00 at separation, The Wife shsll provide docu~entation to
Husband ns to the current stntUII of these debts.
All furthp.r dehts inclIrr"d by thl! rllrti..1I shnll bp thpir individuIII
rl'lIp~nsihilit,. f.ach rnrty nRr..es to inclpmnify nnd hold the other party
hnrml...~ from nncl n~nin~t nny and nil <lIch debts, Ilnbilities or
ohllR,'tinnll "r p.ve.ry kind m"y nri.p. from the "Cor...,'!,1 hill" "nd which,
rUr~lI"nt to the terms h"r"in, nr.. nnt tbp. re~ronsihility of the othl!r
pnrty.
8. MUTUAL RELEASE
Sllhi~ct tn th~ provi~inn~ ~( thi~ ^~rrpmpnt, p~rl, p~rty 11n~ rrlrnsed
nnd dischnr~"d, nntl hy this ARrpcm..nt dn.." for him."lf or hp.r"elf nnd his
nr her heirs. te~;tl represf'lntntives. executors. tuhniniRtrntors Anti
5
811siRnll, releA"e And discharRe the othpr nf nnll frnon nil CAllnes of action,
cl.,imA, riRht.~. "r ctp.manrl.~t Wh:lt8o~Vp.r in t.,w nr ~"lIirYt which ~ithp.r. of
th" pnrti... l!Vl!r had nr nnw hnn n~'1in.t thl' nthl'r, P~PPpt any or all
causell of Actinn for termination of the mllrriall" by "ivorcp nr annulment
and except for any and all caunp.s nf nction for hrpach of any provi.ions
of this ^~reempnt. lIullband and Wifp. srecificnl1y r..(pa.e nncl waive any
and ,,11 rillht he nr .he millht hnvp. to rnin" claimn undp.r thp. Divorce Codp
of 1980, all :Imrndeit, incluclin~, but not limit..d to, dnimll fnr I!quitllble
dilltribll~ioll nf marital property, ns well an qppcific"tly any interest nf
any kind he ~"y hAve had in the property at 122Fi Clnrl'onont ROAcI, Carlisle,
Pelln.ylvnnin, nwnpcl hy Wifl"s parent".
9, DIVISIOR OF PERSORAL PROPERTY
^11 furniture and furnishinlls pr'!"l!ntly in ch" pns.p"sinn nf lIushand
.nel of Wife, illdividunlly, shnll r.mnin thpir serarnrp rrorl!rty an<l ...ch
h'!rp.by t ran" fers to the nth..r any rillh t, tit Ie IIn<l intrrPllt he or sh.. may
h.,v. in the furniture and furnishinlls presently in the possession of the
nrhpr, p~cept for the following items:
Wife IIhAll return to lIusbancl:
ORi Aleetyie hl~"ltyt
n__ It-lilt r~..li~
n~_ ;rg'r'~fqt nlL
Rrnrcnt prnRr~mmnhl~ ~cnnnpr'rP
IIp.r wedrlin~ bnnd
En~al\ement rinR:
^nniversnry rinR:
Fi
HusbAnd h~reby w~ives all int~rellt in Wi'~'1I prop~rty incluclin~ but
not limit~tt to !'Ill Account". W;fp. h.1!l1 no rptirpm"'nt hrn-fit!ll.
WH.. hereby waives all int"r~st in 1I""h.1n,I'" rrnrP.rty inclllding but
not limit~d to all account~. c~rtificAtell of c1ern"it, IIncl securitip'A,
includin~ Capital Products Stocks And CArli.lp Tirl! nncl Rubber r~tirement
bpn..fits. Thp Husband Agrel!s to "iRn AKC rPRi"tration rApp.rs titlin~ the
r,~rti",,' AKC r~~i.~tered dnR. RadiI! Amber, An.\ nny rllppi.." from her litter
whelped in Au~ust-1989 to the Wife.
10, KaIOK VEHICLES
With r,,"p...ct to the mntor vehicle~ owned by onp or hoth of the
pnrti..~, th..y A~r~e nil follows:
(A) The 1986 Ford IlnnR,'r pr"...ntly .inint Iv titl..el, shAll bl!come
And remain the sole nnd excll1~ivr. rrorerty of thr 1I".hnn,J. This v..hicll!
ill .ecurity fnr a Inan with Ford Motnr Comrn"y, nn.1 Hllshnnrl A~rl!eS to
indemnify and hold hnrmll!'s the Wi'~ rrnm any nIl linbility for this debt.
(h) The 1984 Dod~p. Char~er pre'l!ntly titl~r1 tn th~ Wife, shall
becoml! ,1nrl remnin the 1I01e And ....c1llllivr. property nf th" Wife. It is
sl!cllrity for A lOAn at Lnysville Rnnk, "ncl Wi'.. n~r"'PII to indemnify ancl
hole1 hArmlp"" the'HushAnd from any '1nd ,,11 liability for this c1l!bt,
11, WAIVER. OF RIGHTS UWDER. TIlE DIVORCE CODE, AS AllERDED
IIll"h,tnd and Wife specifically relealle and W.~lVP. Any and all right he
or .he miRht have to rnille claims undpr the Divorce Cod.. of 1980, as
am..nded. includinl!, but nnt 1imit~c1 tn. c1.~ims for p,,,dtable c1istribution
nf marital propr.rty, and indpmnify and hold harmlp.lI~ the othp.r from any
7
Auch clAim, Should It divorce Itction he commp.nced hy p.ither of the
rArties, the mnvinR party sh'lll r,,~u~At thl! COllrt tn incnrrnr.,r.. this
ARrprmp.nt intn II Divorcp. Decrl!l!. rf this ARrermrnt i. incnrpnratecl into a
Divorce Decree, the parties shlll1 hnve the riRht t" ~nforce this ^Rreemp.nt
under thp. Divorce Codp. of 1980, a" nm"ndl!d, in ndditinn tn nny rem..c1ies in
law nr l!~lIity, ancl thp.se enforcement riRhts nr.. not w'Iivpd nr rp.lp.nsed hy
any of the prnvis~on" of thill Agrp...ml!nt. n'l! fnct thnt .~ pnrty bringa an
, --
action to enforce--the propp.rty n~reement an incorpnrnt..c1 in the Divorce
Ilecree, ....nder the Divorcl! Cocll' of 1980, ns nml!nded, lines n"t giv" p.ither
p'lrty the right to raise other clnim" unrler the nivorce Cndp., specifically
wnived nn,l rp.lenned by thi. paragrnrh, ,~nd ,,11 ri~hr. .,n" nhl i~ntions nf
thl! pnrtip" nrilllinJt out thp. m.1rrin~r. Rh:dl hp rt,-r,.rminr.d hy thilll
Agrl'l'ment.
12, CUSTODY
1I11Ahand nnd Wife aRr-" that they "h..lI IIhnr.. j"int le~nl ~lIstody of
th" pnrti...' minor childrl!n, n"lZinnin;l: AII~lI.t. 2S, IQ~Q, on rvery nther
Friclay, wh..n the nUll band workll dny., he nh"ll hnvn rartinl cuqtody of the
Children nnd shnll pick them lip After hill IIhift no Fridny; whpn he workll
"l!cond "hift, ~fter work t'n S,.eur.lny; whl'n hI' 'JOrk" rhircl IIhift, on FrielltY
nt 3:001'.10.; nnd he .hall return the Childr..n r.., rh" mnrhl!r ,.e Fi:nO p.m.
nn Sundt'!, in .,11 instnncPf;.
nurin~ thp week the [nther hnn the Childrl!n nn the wpek..nd, he .hnll
hnve partinl c...tody of the Child~.n on.. pveninR rer wP'"k frnm the pncl of
his Ahift until 9:00 p,m,: the week the father doell not have the Children
8
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nn the wQPkend, he shall hnve partial custody of the Children two (2)
"vrninR' per week from the ..nel nf hiq qhift lInril q:on r.m. The father
n~ree. tn prr'lrrnngl! the.e dny, with the moth..r fnrty-eiRht (46) hours in
nelvnnce. It ill underlltond the.e time, are not to cnnflict with pre-school
rro~r~m' or nther IIcheduled ~ctivitie. nf the Chilc1ren, Thl! mother ngrees
tn infnrm the f~ther tim..ly nf such prn~rnms "r Activitil!lI ns they nre
.chrrlllled.
.-1
The father '1~rees to in Corm the mother in ~ timely mnnnl'r if he will
be delnyp.~ in rickin~ up or drorpinR nCf the Chilrlrrn. If he iq mnre thnn
nn,,-hnlC (1/2) h,,"r tat.. in pickinR up the Chil"r"" .,nrl hn. nnt cllllecl the
mnther, thnt visit will he cancclled.
The f.,thpr i!; tn hnv~ pArt i.,1 CI1~tCHty for t'll"'~ ~""'f"k r.nch ~"'nr nnd i!ll
to rrovide the mother three ()) week, "<lvnncr n~tip.e "F th.. datP.~ Rl'lecteel
by him. DlIrin~ this tim"'. the mnthl!r !II h., 1 I h:1V~ CII,tnrly nnr. cv~nin~ from
thr "nd nf hpr wnrkdAY until 9:00 p.m. Thi. "vl!nin~ nhnl1 h.. qcheduled At
th" time the father provides her notice of the e1ntp. nF his wl!ek-lon~
visit.
Thl> Wife ,hnll ~ivp. thrl'e wPl'kn nntic" II[ h"r intrntinn to t~ke the
Children nn vn("~tinn if 1I.,id v"catinn <li.rllpt, 1I11,h.,IllI'. vi.itntion
.rhrdllle.
E.1Ch pnrrnt ~hnl1 hflvl? tp.l~rhnnC' r"nt..,ct ,...itll th,.. r.hi I.frrn nnc~ rer
week when thp Chi Idr..n .'re with rhr. nther p.,rpnt.
Wife ~~reell to HlIllhand having nelclitinnnl, r'!n."n'lhlp ~nd libernl
tempornry phYllicnl cII.tody for purpnses of villit~ti"n nn the r~rtie. m~y
q
.
,
IIllrl!e from time to timp, provide,l Hllsh,~ncl notifi... wi f.. fnrty-..i~ht (46)
hOllrll in .,tiv.,ncp..
13, CUILD SUPPORT
UII"bllnd agrees to pay $41S,OO p..r month chi'! ~u:';"'rt until March 31,
(990, dellignated as $275.00 as the current child support amount and
$1/./).00 "" rllym..nt tow,ucl Rrrellra~es until thp. IIrrellrRp;1!1I are pRid in full
or March 31, 1990; whichever occurs first, and $27S.00 per month
, --
thl!reRft..r. IIpon ~the date of the final Decree in Divorce, the entire
IImnunt ""'"11 he allocated 811 child lIurport,
tn the event there ar.. Any ~lIpp"rt nrre3rllll"q du'!, th.. IIl1sbllnd agreeS
to r,'y the Wif.. "n "dd i t innll I $115.00 r..r mnnth OInt i I "uch t imp. all
.1rr":trnp."s "re t'p.p:tid. Thi~ illl tnw.,rci c:hi 1<1 !ll1I(1pnrt :lrrl".qrI1R""'.
14, WAIVER 01" SPOOSAL SUPPORT. ALJKOIfT PERDEIITE LITE. AIm ALIlfOIIY
Thr rllrti..s herein IIcknowll'dll" thnt by thi" Ap;rrrm"nt th..y hRve nllch
rl!srl'ctively lIl'cureel and mllintllin,,<t II ."hst"nt;nl nnrl .,r1"'l"llrp fun<t with
which tn provide themselves and rh.. Children who mn~ live with them,
~lIfrici"'nt finnnci:Jl t'p.~OllrCPA tn J"rovict~ for thrir Ct'mrnrt, mnlntpnllnc('
nnd ""rport. in the Rtatinn nf lifl! in whirh th.., nr" nccu"tnmecl, Wife
line! lIu.bllnd dn her'..hy wllivp., relell." nnd Ilivn lip IIny rip;htll they lOllY
respectively hllve ap;ain"t th.. oth..r for nlimnny. IIlimnny rend..ntl! lite,
~lIr("nrt or mni"t"n:lnc~. It ~h.']tJ hI" from th... rt.1tt" "r thi~ ^2r~r.ml!nt thp.
.nle r.."pnn"ihility of ench of the reRrectiv.. rnrt;,.. to ""Rtllin
th..mselves without seeking uny ""pport from the nth..r rarty.
10
IS, MEDICAL IRSllRAl'ICIt
Hllsbnncl will cnntinllp. to prnvi<lp mp.<lical in,',r"n".. cnvprnlll! fnr the
Chi Idren and the Wife as 10nR ,H hI> h". nny c1l1ty of '"prort tn them. The
Wifp. will pay all uninsureel meclical, c1entnl, nrtical nr prescription
COAtll, inclucling the inllurance dedllctibll!, nnd .hp. IIhnl1 bp. 1I01ely
entitled to receive any and all in.urnncp reimbllr'l'mrnts ancl Major Heclical
inAllrllnce refuncla }hereon.
. -~
The Wife agreea to provide the HusbAnd with hilla or statements for
filing with the insurance carrier in a timely manner. The Husband agree.
to tllrn nV~r nIl insuranc.. rrocep.c1s nncl Hn jor Ml'di"Al inllllr'lnce refund
chrck. to Wire within fiv~ (S) days nf his receipt of snme.
III1.bnnr! ,'~rc"s to provirle Wife all neceAAAry numbers, cArdA and form.
necrssary to cnrry out thl! intp.nt nf the above rnrAllrAphs.
Ihlllb"nd nlilrees to pny one-ha 1 f (1/2) .0 f nny ~"'l rnnr,li nllry med icnl
exp..nse for the Ch i Idren not coverer! by inllurnnct', i nrl lI.ling cnAt for
orthndnntllrp., i.f nC'Cp.ss.1ry. The dpcicdnn to incllr ,.xtrl'ft)t"Cfinary medical
"xrP.nlles IIhal1 be a Joint nn.., an<l Hu.b"nd nllr-". nnr to withholc1 his
l~"n~rnt for :'"Y :luch p.xppnRe~ wh leI! wnt,l rl hp r~"!tnn:'1h I y nr.cP!ll~,qry.
16. LIFE IRSDRANC!
The rnrtie. wnrrnnt nnd repr...ent r.h"t th"y <hnll nnmp. thp. Children
.,~ irrE-vocnhl" hcnp.fici.qri~!lI fMr .1~ l","g .,q th."y h!'lv'" :t dllty of !lItJrpnrt,
nn the pnlicil!s of inAllrnnce nn thrir I iv'!. a. r-rr"<ent-r! by thp. nttached
li.ting incluclrd on Appendix "A" attnch..d hrrl!to anr! mn<le n pRrt hereof.
Each party warrants that they have not mnr!" nnd will nnt make any 10Rns or
11
'.
00 '0
a,"i~nm..nts uncl'!r such policiell, IIncl will "'lr cnnerl nr '"rrl'ndp.r sllch
policies. Upnn the other'lI requl!.t, ..ith..r pnrty _h.,11 r.X"Clltl! Ilny
document npce.lll1ry to effect 11 conv'!rsiun or .~Ject nn nrtion uncl..r any
qllch pol icy, Roth parti... agree to make pllymp.nt of prp.miums on the
policielt on their individual liv'ls 110 as to continllp. ltnicl cnvp.ra~e aa long
as the Children nre owed a dllty of IIl1rport,
17, LEGAL COURSEL
--
Hushand i8 ri!'presentl!d by thl! ll1w office of 1I0LHAH & 1I0LH^N. and wi fe
.
i It reprMcntl!c1 by Ruhy D, Wel!ks. F:sqn i rl!, nn.1 ench nf the rllrt jell ngree
that they have entered into this ^~r"ement with a cnmrlete IInderstancling
of the contp.nts thereof .,nd after comrlete di~clo.ur" nf nIl IIssets,
lillbilities and rights thllt they each may hllve.
18. ATrOIUIEt FEES. COSTS & En'DSES
The rnrties agree to waive receirt o~ and to be responsible for their
own nttorn~y fe~A. costs and p.xpcn~~~o
19, ERP'ORcomlrJ:
If ..ithl!r rnrty brnnrh". nny rr'lvlsinn nf this Agrl!emrnt, the othl!r
p"rty .hnl1 hllve thp. right, nt hi~ nr h'!r ..lpctinn, r'l IIUt' fnr damn~~s for
sllch brellch or tn :lIeek nther remcrl I". nr r..J i,.f "" mny be nvni 11lhl.. to him
nr her. IInrl thn rnrty brl!lIchinlt this Al(re"mr"t _h"ll b" r'!ar'lnsibt", for
r,'ymC!nt nr r"nqnn.,hlr. 1"v..,1 frPA .,nrl cn~t~ inC"llrr,..11 hy rhp nth~r in
-:,nfnrcinR hi" fir hpr rillht!l; IIncf"r thi~ ^Rrc"m"nt. F'.,i furl! to ~eek a
r..m~dy fnr on'! or more br..nche. shnll not he d,.",mpr! n wniver of IIny
.ubsequl'nt hreneh.
12
.
,
.
.
20. ADDtTtORAL t"STlUIHERTS
F.llch of the partie. shall from time to tlmp, nt th" r"'1",,"t of the
other, execute, acknnwleclRe, and rl"llver to the nthpr party IIny IIncl all
further inlltruments that may be rea~onahly rp.'1ulrecl to ~ive full force and
effect to the prnvisiona of this ^~reem"nt.
'-
21. APPLICAJlUI: LAW
-.,.
Thill ^~reemeht shall be conatrued unclrr the laws of the Cnmmonwealth
of PennsTlvania.
22, VOID CLADSES
rf any term, clalllle, cnnclition or provisinn shall hl' <lp.termin..d or
rlccl~r~lf tn h~ vnid or invnlirl in Inw nr ntll~rwi~r. th~n nnly thnt tprm,
clause, condition or prnvision .hnl1 be IItrick"n from this ^~rrement and
in All other rp.llpect this Agreement ~hall .be vallrl nnrl continup in full
f"rce, effect nnd operation.
23, BIRDIJ/G uncr
Thl. Agreement shall be binclin~ "r"n ~he rp.",,~tivP n'lrties, their
h~ir!, nxecutors, administrators, successors and n~nigns.
,
24. DESCRIPTIVE IlEADIRGS
The c1eacriptive h"n~ing' ""ed hprein are for crnvenience only. They
ohnll h"vp' no "rrP.ct whntaop.vpr in r1p.t"rmininR th" riRht. or ob1i~"tions
nf the parti....
13
~
25, ERTlRE ACR!EHEIfT
This ^~r~p.mpnt contains thl! ~ntirp lIncl~r"tnnrlinR "f rh~ p'lrti~" and
thrrr nre no rppreA~nt~tion", covpnnnt~ nr Ilnrlrrt~ki'I~~ nth~r thnn tho~Q
pxpr""s1y set forth her~in,
TN WITNESS WHEREOF, the partie" hRve herellnt" 1I~r. thpir hRncls Rnd
(j;.";j;;~'
IIbnve uri ttpn.
,
,
14
o.
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,
,
,
Al'PUDU "A"
LIFE INSURANCE POLICIES - PARAGRAPH 16
Policiea on the Ruaband:
Company:
Policy Humber:
Amount:
Beneficiariu:
:..
.";,-
, --
.-.. .
Policiea on the.Wife:
COlllpany:
Policy Humber:
Amount:
Beneficiadu:
:
., -
Aetna
2626-11
$26,000,00
~ale Cendal1 Bridle
Brice Elliott Bridle
r
HILICO
0420S49014
$100,000,00
~ale Cenda11 Bridge
Brice Elliott Bridge
- If children are lIIinora-then to Doria
. R, Weibley in Trust for children
,
"
,
.
,
,
.
,
-
COHMONWE^I.T~OF PENNSYLVANIA ~s
COUNTY OF ~1I
On this,
the.3/ffdItY nflJcht(~___, 1'1(t,
bef"rl! me, a
N"tmry Public, the uncl~rlligned "fficer, p..r~"nnlly npre~recl JODY L.
IIR I liCE , known to mp. to be th.. pl!r.nn wholl.. n"m~ is lI"h~c,ihpcl to the
wi thin Prop~rty Sttt lem"!nt Agr"em"nt, nnd ncknnwl..rllt"d thllt hp. ..xecuted
the qnm~ for the,~rpo.e. therein contninpcl.
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c:.raII...... ,." CIIInIr '., '.0 ";
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COHHONWF.ALTR OF PENNSYLVANIA :
: ~s
ClIIINTY OF CUMIIF.RLAND
On th;q, th" ~#\ rlny nf ~'(faJ~__' 1'l.1j, h"fnr.. m", ..
Hnt.u, r"hl ir., th.. "nrl"rqiRnrrl nffir...., rr.q"I1.,1 Iv "1'1'".,.,,<1 DEBORA" W.
nR111r.F., kno....n tn rnt' to hI" th#t p~rqnn wlun;,.. n~M" i~ cllh~t:rihl'tri to thp
within rrnpprtv ~.,.ttl"m,.nt ^~rrpm"'nt, .,nd :1ckru""I".Iv.t'I.1 th.qt Ahp p.'Ct"cnt,.rl
',-
r-Itf" q:'lm~ fnr th~ pllrrrHH~~ ther~in rnnt.,inrd.
._21h~.,,4:_0~,
Nnt.,ry Pllhl i r
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NOTARIAL SEAL
SHARON A. DIEHL, NOTARY PUBLIC :, ,. "
CARLlSl.E BORO, CUM6EilLANO COUNTY;''..'' .' : ,;,)
MY COMMISSION EXPIRES FEBRUARY 22. 1983. :'/:~
.
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15
Franco Psychological Associates
Z6 St.te Avenue C.rliJle, PA 17013
(717) Z43-1896 Fu (717) Z43-5Z97
Nancy M. Small. A.C.S. W.
Licallcd Social Worker
CUSTODY EVALUATION
CHILDREN: Kale Kendall Bridge
D,O.B, 4/7/86
Brice Elliot Bridge
D,O, B, 9/21/87
PARENTS: Father: Jody Bridge
D,O.B, 8/15/64
5 Front Street
Boiling Springs, P A 17007
Mother: Deborah Stackfield
D,O, B, 5/25/66
1226 Claremont Road
Carlisle, PA 17013
Counsel for Father: Barbara Yunis, Griffie & Associates
Counsel for Mother: Joan Carey, Legal Services
, ..,l..._., .:;,~'
Page Two
Contents:
A Recommendations
B. Discussion
C. Supporting Data
1. Relationship History
2, History of Custodial Arrangements
3. Impact on School Career
4, Parental Assets and Liabilities of the Mother
S, Parental Assets and Liabilities of the Father
0, Sources ofInfonnation
Page ll1ree
A. Recommendations
While the father's concerns are legitimate, I am recommending that the boys
remain in the primary care or their mother at this time, I am very concerned about the
physical and emotional safety and security of these boys if the pattern of domestic violence
and drug abuse by Mr. Stackfield were to continue in the mother's home, Both Mr, and
Mrs, Stackfield are in appropriate treatment programs, The incidents of concern are not
occurring at this time to my knowledge.
B, Discussion
The circumstances which Ip.d to Mr. Bridge's filing of a custody petition raise
several questions, there has been domestic violence perpetrated by Milton Stackfield to
Deborah Stackfield, Milton Stackfield relapsed in drug abuse and drug dealing during the
time he was living with Deborah and her sons. Despite these incidents, Deborah
proceeded to marry Mr. Stackfield on May 4, 1994, The questions raised include:
1. Deborahls judgment as it applies to providing a safe, secure environ-
ment for her sons,
2. How much of the above incidents have the boys been aware of
or exposed to.
3. If the boys have been exposed to domestic violence or a drug abuse
environment, what have been the effects on them
I believe that Deborah is making progress in the areas of self esteem and judgment.
I believe that, although the boys have been shielded to a great degree, they have some
awareness of or have wiblessed some events that have been upsetting to them I believe
that the atmosphere and events which they have experienced in their mother's home have
had some negative impact on the boys, Specifically, I believe they are more anxious, dis-
tracted and fearful as a result.
The last question is, are these experiences and effects of a serious enough
consequence to disrupt their current living and school arrangements. I would recommend
the change to the father's primary custody only if these experiences continue,
No one can accurately predict future behavior, Mr, Stackfield's past record is one
of recurrent relapses. I do not feel he is doing all he could do to prevent another relapse,
I am encouraged by Deborah's progress and seemingly sincere desire to provide a secure
home for the boys,
Beyond the recommendation for custody, I would share the following thoughts,
Perhaps the parents should set up a phone conference time to discuss the boys' needs
when the boys are not present
Page Four
Apparently transfer times have been the times for these discussions and may have
presented parental conflict in front of the boys. Also both parents and their spouses
should refrain from disparaging remarks about the other or sharing adult concerns with the
boys,
C, Supporting Data
1. Relationship History
The couple met in approximately 1982, They were introduced by
Deborah's mother, They married on September 29, 1984, The couple
separated in 1988 when lody Bridge left the marital home,
Mr, Bridge remarried his current wife, Lisa, December 21, 1990,
Their household includes Mrs, Bridge's two daughters, ages 6 and
11 and lody and Lisa Bridge's daughter, Kara, age 3,
Deborah had another son, Ty, age 2. Ty's father is Kenneth Winston. He
resided with Deborah from March 1991 to September 1991. Deborah was
married to Milton Stackfield on May 4, 1994, The couple had lived together for
approximately 2-1/2 years prior to their marriage.
Milton Stackfield has three sons, ages 7,5, and 3 who visit Milton and
Deborah two times monthly for weekend visits.
2, History of Custodial Arrangements
At the time of separation in 1998, the father left the marital home. The
children remained in the primary care of their mother, She has remained the
primary caretaker to this date, The filther has been very consistent in exer-
cising visitation with the boys, The father has consistently paid child support,
3, Impact on School Career
Both boys attend Middlesex Elementary in Cumberland Valley school
district, A change in primary custody to the father would mean a change of
school district for the boys, Comparable services to meet the boys' educa-
tional needs are available in either school district.
Kale is in 2nd grade, Brice is in 1 st grade, The school is aware that both
boys may have some special educational needs in the areas of ability to stay on
task, assessment for possible learning disabilities and speech development.
Further evaluation has been deferred until this custody proceeding is
concluded, The mother has been consistently involved in the boys school career
and coordination with the school. According to the school guidance counselor,
Page Five
she has been responsive to any suggestions by school personnel. She obtained
tutoring in the summer for both boys, Homework supervision appears ade-
quate in the mothet's home. The guidance counselor reported that the boys are
adequately dressed and supplied for school.
The father and his wife have been increasingly involved with the school
also, participating in decision making and attending school functions.
Page Six
4, Parental Assets and Liabilities of the Mother, Deborah Stackfield
Assets
Has been the boys' primary caretaker
since birth.
Consistent work history, at times working
an additional part time job,
Supports the boys involvement in age
appropriate activities.
Has cooperated and actively participated
with school personnel. VolWlteered at school
Provided additional tutoring for boys.
School personnel are very aware and involved
in the status of both boys' educational needs,
Emotionally invested as a parent. Does many
thoughtful "little extra" things for the boys.
Extensive family support, Maternal grandparents
live almost next door and have been significantly
involved with the boys.
Appears sincere about personal growth, Con-
sistently attends therapy for self and the boys,
Has shown progress according to Stevens Center
therapist, Melissa Werle.
Participants in a domestic violence support group
weekly.
Milton Stackfield has consistently attended out-
patient 0 & A therapy at the Stevens Center,
Milton Stackfield has had no parole violations,
Liabilities
Husband, Milton Stackfield, has been
convicted and incarcerated for drug
violations, Another charge is pending,
If convicted, further prison time is a
possible sentence,
Documented history of domestic vio-
lence pelpetrated by Mr. Stackfield
to Deborah Stackfield, The incidents
often seem to be concurrent with Mr,
Stackfieldls drug use periods, Boys
have some awareness of conflicts
and/or violence in the home,
Milton Stackfield has a history of
crack cocaine abuse, He has had S
inpatient rehab treatment experiences.
He has relapsed after the first 4,
Milton Stackfield has not been
attending meetings which could de-
crease the probability of another re-
lapse,
Page Seven
S, Assets and Liabilities of the Father, Jody Bridge
Assets
Liabilities
Legitimately and sincerely concerned about
sons' well being,
Work history was inconsistent
when children were young,
Has consistently exercised visitation rights
and paid child support.
History of substance abuse more
than 10 years ago,
Appears to provide age appropriate activities,
Allegations that Jody and Lisa are
less attendant to the boys' personal
care.
Wife, Lisa, demonstrated very good parenting
skills,
Consistently employed since 1987,
Apparent marital stability,
No current or recent drug or alcohol
abuse by either Jody or his wife, Lisa,
Extended family support.
r
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i:
Page 8
D, Sources of Infonnation
1. Individual interviews with:
a. Jody Bridge, father
b, Lisa Bridge, stepmother
c, Deborah Stackfield, mother
d, Milton Stackfield, stepfather
e. Doris Weibley, maternal grandmother
f. Mr, W, Weibley, maternal grandfather
g, Kale Bridge
h, Brice Bridge
2, Joint Observations
a, Jody and Lisa Bridge and both boys
b, Deborah and Milton Stackfield and both boys
3, Other Sources
a, Written report, Cumberland County Probation
b, Interview with therapists, Melissa Werle and Becky Lane,
Stevens Center.
c, Reviewed school reports
d, Telephone conversation with Jacqueline Granite, school
counselor
e, Written report from Karen Hackman, therapist, Christian Services
f. Police records
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JODY L, BRIDGE, , IN THE COURT OF COMMON PLEAS OF
,
Plaintiff , CUMBERLAND COUNTY, PENNSYLVANIA
,
,
,
vs, NO. 2347 - CIVIL - 1994
DEBORAH W, BRIDGE, ,
.
(STACKFIELD) .
,
Defendant , CIVIL ACTION - CUSTODY
,
-, , r" r
,'J( .
AND NOW, this 'day of
COURT ORDER
'. ',,:.r'?~ lIt f-t /; 1994, upon consideration of the
attached Motion for continuance, the matter scheduled for hearing
on October 3, 1994, at 9:00 a.m, in Courtroom No, 1 of the
Cumberland County Courthouse, Carlise, PA has been continued until
the 21st day of December, 1994, at 9:00 a,m,
BY THE COURT,
jj;, ,j/.Jf~-
Harold E, Sheely, J,
t-.
-
5tp:)O 3 13 ' ;1 '91\
; ~
JODY L, BRIDGE,
Plaintiff
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
: NO, 2347 - CIVIL - 1994
vs,
DEBORAH W, BRIDGE,
(STACI<FIELD)
Defendant
,
.
,
,
,
.
CIVIL ACTION - ct1STODY
MOTION FOR CONTINUANCB
The petitioner, Jody L, Bridge, as an adult by and through his
attorney, Barbara J. Yunis, states to following:
1. The petitioner, Jody L, Bridge, is an adult individual
residing at P,O, Box 352, 5 Front Street, Boiling Springs,
Cumberland County, Pennsylvania,
2, The respondent, Deborah Stackfield, is an adult individual
residing at 1226 Claremont Road, Carlisle, Cumberland
County, Pennsylvania,
3, Petitioner filed a complaint for modification of custody on
May 3, 1994.
4, A custody conciliation was held on Thursday, July 21, 1994
at which time the parties could not reach an Agr<eement
relative to custody.
5, By Order of the Court dated August 9, 1994, a hearing was
scheduled in Courtroom One of the Cumberland county
Courthouse on Monday, October 3, 1994 at 9:00 a,m,
. ,
, .
6, After the Order of Court dated August 9, 1994, the parties
secured an independent couselor, Nancy Small of Franco
Psychological Associates, to present to the court a
statement of her recommmendation concerning the best
interest of the children in this action.
7, On Tuesday, September 27, 1994, Ms, Small contacted
petitioner stated that she would not have the parties'
custody evaluation prepared by October 3, 1994,
8, The petitioner requests a continuance of the hearing on
October 3, 1994 for the following reasons:
a, Allow Ms, Small ample time to properly prepare the
custody evaluation for the court to review,
b, Allow the parties time to review the evaluation prior to
the hearing in hopes of facilitating an agreement,
9. Respondent's attorney, Joan Carey of Legal Services Inc"
agrees to the continuance.
WHEREFORE, the petitioner requests that the hearing be continued.
Respectfully submitted,
:J .
,fl, ~~VL
Barbara
~..,;'--...- ....
VBRXJ'XCATXON
I VERIFY THAT THE STATEMENTS MADE IN THE FOREGOING MOTION
ARE TRUE AND CORRECT. I UNDERSTAND THAT FALSE STATEMENTS HEREIN
MADE ARE SUBJECT TO THE PENALTIES OF 18 PA,C,S, SECTION 4904
RELATING TO UNSWORN FALSFICATION TO AUTHORITIES,
DATE: 9!)q)1f
;?~/ Z bA~-
DY ,BRIDGE
vs.
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO, <1'1,;; 3'/ 'l !.','"'f 7'1 ,,,-
JODY L, BRIDGE,
Plaintiff
,
,
,
,
,
.
DEBORAH W, BRIDGE,
Defendant
IN CUSTODY
APPIDAVIT OP SERVICE
I HEREBY CERTIFY THAT I served a certified copy of the
Petition For Modification of Custody, dated May 3, 1994, upon the
Defend~nt, Deborah W, Bridge on May 13, 1994, and received on May
14, 1994 by certified mail at the following address:
Deborah W, Bridge
1226 Claremont Road
Carlisle, PA 17013
I verify that the statements made in the foregoing Affidavit
of Service are true and correct to the best of my knowledge,
information, and belief, I understand the false statements
herein made are subject to the penalties of Pa,R,Civ,p 404
relating to unsworn falsification to authorities,
GRIFFIE & ASSOCIATES
.)",1 [.J() . nqy'
v ,.
,., (/~ ,,'~
Y nis, Esquire
200 North Hanover Street
Carlisle, PA l7013
DATE
to', ,C
: I""-:SENDER:
- :. Complete Rima 1 andJot 2 for .dditkJnll "Me...
,- CompIet. It.m. 3. .nd 4. 6 b.
. Prtnt ycM' neme .nd Iddre" on the ,.v.,.. o' ttM. form so thlt w. can
mum ,hit c.rd to you.
. AttKh th&I lorm 10 the front of the m.UpI.e.. or on the blck If .~C.
don not permit.
.. . WritI"R.tum R.celpt R~.ttd" on the nWl~ beJow the Irtidt number
.. . The Return Rec:.~. will thow to whom the .nld. WI' dtUwted and the d.l.
I deNVII,IId. Consult I.mlllter for fee.
13, ArtJcl. Addr...ed 10: 4., ArtJcl. Number
Deborah W. Bridge P 302 64C 430
1226 Claremont Road 4b, S.rvlc. Typ.
Carlisle, PA 17013 0 Regllt.red Olnlured
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RECEIPT FOR CERTIFIED MAIL
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.u.a. GPO: 1113--352-714
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DOMEST C RETURN RECEIPT
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JODY L, BRIDGE
Plaintiff
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
vs.
NO, 94-2347 CIVIL TERM
DEBORAH W, BRIDGE (STACKFIELD): CUSTODY
Defendant
.
.
DEFENDANT'S WITNESS LIST
The defendant has been the primary caretaker of the children
since their births, and as such has provided for their needs.
The plaintiff raised the issue of the effect of the defendant's
husband's behavior on the children, but in fact, his behavior has
had no adverse effect on the children and he has never harmed the
children, Therefore, there is no basis for changing custody from
the mother who has maintained and can continue to maintain a
stable environment for the children,
The defendant, DEBORAH W, STACKFIELD, formerly Deborah
Bridge, by and through her attorney, Joan carey of Legal
Services, Inc" sets forth this list of witnesses along with a
summary of their expected testimony for a hearing to be held on
October 3, 1994, at 9:00 a,m, in Courtroom No, 1.
1, Deborah w, Bridqe: (717) 258-1789, 1226 Claremont Road,
Carlisle, PA 17013, The defendant to testify about her ability
to provide for the needs of her children, the circumstances under
which the children live in her home, and their relationship to
Milton Stackfield and to the plaintiff,
2, Milton Stackfield (717) 258-1789, 1222 Claremont Road,
Carlisle, PA 17013, The defendant's husband to testify to his
relationship with the defendant and her children with whom he has
lived for approximately three years except for a period of about
six months in 1993,
3, Doris Weiblev: (717) 249-2030, 1222 Claremont Road,
Carlisle, PA 17013, The maternal grandmother to testify about
the children's relationship with the defendant and her husband,
their parenting abilities, their relationship to the father, and
the children's relationship to the grandparents.
4, Pearl Bouder: (717) 243-5592, Epply Drive, Carlisle, PA
17013, Long term family friend to testify to the mother's
relationship with the children, her parenting abilities, and the
relationship of the children with Milton stackfield and the
defendant.
5, Judv Gutshall: (717) 789-4110, R,D, #1, Box 347,
Loysville, PA 17040, Defendant's sister to testify about the
children and their relationship with plaintiff, defendant, and
Milton stackfield, and the children's relationship with her.
6, Alice Hipp: (717) 597-9060, 1401 Brenda Drive,
Greencastle, PA 17225, Defendant's sister to testify about the
mother's parenting ability, and their relationship with defendant
and Milton Stackfield,
7, Donald Orth: (717) 249-8282, 1836 Mary Lane, Carlisle,
PA 17013, Defendant's brother to testify about defendant's and
Milton Stackfield's ability to care for the children and their
relationship,
8, Kellv Macomber: (717) 697-3144, 806 Lancelot Drive,
Mechanicsburg, PA 17055, Friend of the defendant to testify
---'.;~..,.....':-
about defendant's parenting ability and interaction with her
children,
9. Kristi Schell: (717) 243-0550, Appalachian Drive,
Carlisle, PA 17013, Friend of the defendant to testify about
Milton Stackfield and his relationship with the children and
situations involving Milton,
10, Stephanie Rhoads (717) 258-6213, 294 Walnut Bottom
Road, Carlisle, PA 17013, Friend of the defendant to testify
about defendant's efforts to work through issues related to past
domestic violence.
11, Kale Bridqe, 8 vears old and Brice Bridqe, 6 vears old:
Defendant's children to testify in Judge's Chambers regarding
relationship to plaintiff, defendant, and their spouses.
12. Middlesex Elementarv School staff includinq Ralph
Johnson. principal, Susan Burkett, teacher. Mrs. catalono,
teacher, Jackie Granite, school counselor, Sharon Chisar,
teacher, Donna Pletcher, teacher: (717) 249-5586, 250 North
Middlese Road, Calrisle, PA 17013, School staff to testify to
defendant's involvement in children's education and other related
school activities, and their knowledge of the children,
13, Lvnn Sherrif: (717) 243-3758, 115 North Middlese Road,
Carlisle, PA 17013, Defendant's children's tutor to testify to
defendant's involvement in children's education and her knowledge
of the children.
14, Nancv Small: 26 State Avenue, Carlisle, PA 17013.
Independent therapist to testify to her knowledge of the family.
The defendant reserves the right to call other witnesses
upon reasonable notice to counsel,
Respectfully submitted,
J an Carey
ttorney for Def ndant
LEGAL SERVICES, INC.
8 Irvine Row
Carlisle, PA 17013
(717) 243-9400
SfP 23
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The above-named Defendant, Deborah W, Stackfield, verifies
that the statements made in the above Witness List are true and
correct, Defendant understands that false statements herein are
made sUbject to the penalties of 18 Pa, C.S. 64904, relating to
unsworn falsification to authorities.
Date:
CU3.3.jtl "-
AUG 0 3 199~
J~
JODY L, BRIDGE,
Plaintiff
:IN THE COURT OF COMMON PLEAS OF
:CUMBERLAND COUNTY, PENNSYLVANIA
:
v
:NO. 2347 - CIVIL - 1994
,
,
DEBORAH W, BRIDGE,
Defendant
,
,
:CIVIL ACTION - CUSTODY
COURT ORDER
AND NOW, this tjtJlday of ;)/.1(,0 f.. /, 1994 upon
the attached Custody Conciliation Report, it
directed as follows:
consideration of
is ordered and
1.
A Hearing is scheduled in Courtroom No, 1 pf the.Cumberland
County Courthouse on the i /', Iday of ,) { I" I, CI,-_, 1994, at
-/; /JU"M, at which time testimony in the above case will be
taken: At this time, the Father, Jody L, Bridge, shall
proceed initially with testimony. Counsel for the parties
shall file with the Court and opposing counsel a Memorandum
setting forth each party's position on custody and also
setting forth a list of witnesses that each party will call
to testify at the Hearing along with a summary of the
anticipated testimony of each witness, This Memorandum
shall be filed at least ten days prior to the Hearing date,
Pending further Order of this Court, the children shall
remain in the primary custody of the Mother in accordance
with the November 6, 1989 Custody Agreement, The provision
restricting the Mother's ability to remove the children from
the Commonwealth of Pennsylvania is lifted so that Mother can
take the children out of state on vacation,
2,
3,
In the event Milton Stackfield is released from prison prior
to the scheduled Rearing date, Mother shall not allow Mr,
Stackfield to live with her without first notifying Father's
counsel to give Father's counsel an opportunity to present
a Petition to the Court seeking special relief on that
particular subject,
BY THE COURT,
C~.'{~--
J
cc: Joan Carey, Esquire
Barbara J, Yunis, Esquire
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Of'" 1',lllljll~1AhY
CUll\:: '< ,.'.1) C<JIlTY
P[HS'J~L':;''',:.\
...
JODY L, BRIDGE,
Plaintiff
: IN THE COURT OF COMMON PLEAS OF
:CUMBERLAND COUNTY, PENNSYLVANIA
,
,
v
:NO, 2347 - CIVIL - 1994
,
,
DEBORAH W, BRIDGE,
Defendant
,
.
:CIVIL ACTION - CUSTODY
PRIOR JUDGE: JUDGE HAROLD E, SHEELY
CONCILIATION CONFERENCE SUMMARY REPORT
IN ACCORDANCE WITH CUMBERLAND COUNTY RULE OF CIVIL PROCEDURE
1915,3-8(b), the undersigned Custody Conciliator submits the
following report:
1. The pertinent information pertaining to the children who
are the subject of this litigation is as follows:
Kale Cendall Bridge, born April 7, 1986 and Brice Elliott
Bridge, born September 21, 1987,
2, A Custody Conciliation Conference was held on July 21, 1994
with the following individuals in attendance:
The Father, Jody L. Bridge with his counsel, Barbara J,
Yunis, Esquire, and the Mother, Deborah W, Bridge, with
her counsel, Joan Carey,
3. The parties reached a Property Settlement Agreement in
November of 1989 which included an arrangement on custody,
At that time, the Mother was given primary physical custody
of the two minor children with the Father having temporary
custody on alternating weekends and on two evenings per week
on the weeks he did not have the children on the weekend.
4, Father became concerned when Mother saw a newspaper article
that suggested that the Mother's live-in boyfriend, Hilton
Stackfield, was involved in drug activities and also involved
in some abusive behavior towards the Mother. Father filed a
Petition for Special Relief to have the custody changed to
him. By Order of May 18, 1994, Judge Sheely determined that
a Hearing was not necessary under Petition for Special Relief
because of the fact that the live-in boyfriend, Mr, Stackfield,
was going to jail, Mr, Stackfield and the Mother, Deborah W,
Bridge, have since married on May 4, 1994 immediately prior to
Mr, Stackfield going to rehab and then to prison,
5, Father now wants to have custody of the children, Father
suggests that Mother has demonstrated a lack of concern for
the children merely because she lives with a man who is
involved in illegal drug activities and because she allows an
abusive domestic situation to be present in front of the
children, Father also suggests that Mr. Stackfield is abusive
towards the children, Mother indicates that the children have
never been subjected to abuse by Mr, Stackfield nor have the
children been witnesses to any abusive or criminal conduct
while they are in the home. Mother desires to keep the custody
arrangement as it has been since 1989,
6, It is clear the parties cannot reach an agreement, A Hearing
is necessary, The Conciliator recommends an Order in the form
as attached,
.,gJ,lq"
DATE
Hubert X, Gilroy, squire
Custody Conciliator
'-,_.;'.bI!';.'.'"
JODY L. BRIDGE
Plaintiff
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL ACTION - LAW
NO, 94-2347 CIVIL TERM
IN CUSTODY
ORDER OF COURT
V
DEBORAH W, BRIDGE
AND NOW, May 18, 1994, the hearing set for Thursday, May 19,
1994 is CANCELED,
The custody decision will await the order from the custody
conciliator. Should there be a need for the court to be involved
before the conciliation upon proper petition I will set another
hearing,
Pending a hearing before the custody conciliator the natural
mother will not remove the children from the Commonwealth of
Pennsylvania,
BiJ:L ~~~;;::J~-
Harold E, Sheely, P,J.
Joan Carey, Esquire
Legal Services, Inc,
Barbara Yunis, Esquire
:sld
/16, m' 'n I. I
0' ~';H
PETITION FOR CONTINUANCE
The petitioner, Deborah stackfield, formerly Deborah Bridge,
by and through her attorney, Joan Carey of Legal Services, Inc.,
states the following:
1, The petitioner, Deborah Stackfield, is an adult
individual residing at 1226 Claremont Road, Carlisle, Cumberland
county, Pennsylvania.
2, The respondent, Jody L, Bridge, is an adult individual
residing at P,O. Box 352, 5 Front Street, Boiling springs,
Cumberland County, Pennsylvania,
3. On or about May 3, 1994, the respondent filed a Petition
for special Relief in the above-captioned case, and on May 6,
1994, an Order was entered scheduling a hearing for May 19, 1994
at 3:00 p,m.
4, The petitioner was served with the Order and Petition on
or about May 14, 1994 and contacted several attorneys in an
effort to retain counsel,
5, Legal Services, Inc, became aware of the petitioner's
hearing at approximately 6:00 p.m, on May 17, 1994 and scheduled
an appointment for 8:30 a,m, on May 18, 1994.
6, The petitioner requests a continuance of the hearing on
May 19, 1994 for reasons including the following:
.
;'
a, Legal Services is unable to properly prepare for a
hearing,
b, The dangers averred by the respondent do not exist since
Milton Stackfield does not currently reside with the
petitioner, since May 4, 1994, Milton stackfield has been
at Roxbury Treatment Center in Shippensburg pursuant to this
Court's Order, See Exhibit "A" attached and incorporated by
reference,
WHEREFORE, the petitioner requests that the hearing be
continued and that the matter of custody be resolved at a
conciliation conference,
Respectfully submitted,
/-
~rb
Attorney for Pe ~tioner
LEGAL SERVICES, INC,
8 Irvine Row
Carlisle, PA 17013
(717) 243-9400
""'.....
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DEBORAH W, BRIDGE,
Petitioner
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
94 - 1559 CIVIL TERM
CHARGE: INDIRECT CRIMINAL
CONTEMPT
V,
MILTON L. STACKFJELD,
Respondent
IN RE: PFA CONTEMPT
ORDER OF COURT
AND NOW, May 4, 1994, upon the joint request for continuance by the
Commonwealth and by Public Defender, Timothy Clawges, Esquire, the hearing
on this matter is continued generally to the call of the District Attorney, on condition
that the respondent attend and successfully complete the in-patient program at the
Roxbury Treatment Center in Shippensburg,
By the Court,
J,
Travis Gery, Esquire
Assistant District Attorney
Timothy Clawges, Esquire
Assistant Public Defender
St.f+i (j ( r
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The above-named Defendant, Deborah W, Bridge, verifies that
the statements made in the above Petition are true and correct.
Defendant understands that false statements herein are made
subject to the penalties of 18 Pa, C,S, 64904, relating to
Date:
5 ' \ ~. _C\ "-t
authorities,
~l'''~c,c w~d!'-
Deborah W, Bridge, De ant
unsworn falsification to
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JODY L, BRIDGE, IN THE COURT OF COMMON PLEAS OF
Plaintiff , CUMBERLAND COUNTY, PENNSYLVANIA
,
vs, : No. 2347 CIVIL 1994
,
,
DEBORAH W, BRIDGE, , CIVIL ACTION - CUSTODY
,
Defendant
PLAINTIFP'S AMBNDBD PRETRIAL STATBMBNT
Plaintiff, Jody L, Bridge, filed his Pretrial Memorandum on
or about September 21, 1994, pursuant to the Court's Order of
August 9, 1994, A hearing on the matter has been scheduled for
December 21, 1994,
At this time, Plaintiff wishes to update the witness list
set forth in his original Pretrial Memorandum to include the
following witnesses:
1,
William Weibly, 1222 Claremont
CarliSle,
Road,
Pennsylvania, 17013,
Mr, Weibly is the children's maternal
grandfather, He shall testify relative to his relationship with
the children, as well as his relationship to the Petitioner.
2, Ronald Bridge, RD1, Shermansdale, Pennsylvania 17090,
Mr. Bridge will testify relative to the Plaintiff's and his
wife's relationship with the children, their parenting abilities,
the
children's relationship to Plaintiff, and
Plaintiff's
employment history,
1
~
3, David Myers, Probation Department, Cumberland County
Courthouse.
Mr, Myers will testify relative to Defendant's
husband's criminal record,
Respectfully submitted,
Attorney for Plaintiff
By ;il~~-l(- J{/uHM
Barbara J,/Y is, Esquire
Griffie & Associates
200 North Hanover street
Carlisle, PA 17013
(717) 243-5551
2
'"
I
.
VERIFICATION
I verify that the statements made in the foregoing document
are true and correct, I understand that false statements herein
are made subject to the penalties of 18 Pa.C,S. section 4904,
relating to unsworn falsification to authorities,
DATE:
/;l~?/<J'I
. ~~
~~'-~/;.' ~ -tA~V
DY ,BRIDG"
1.
William Weibly, 1222 Claremont
Road,
Carlisle,
JODY L. BRIDGE, , IN THE COURT OF COMMON PLEAS OF
,
Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA
vs. No, 2347 CIVIL 1994
,
.
DEBORAH W. BRIDGE, : CIVIL ACTION - CUSTODY
Defendant ,
,
PLAINTIFF'S AMENDED PRBTRI~L ST~TEMBNT
Plaintiff, Jody L, Bridge, filed his Pretrial Memorandum on
or about September 21, 1994, pursuant to the Court's Order of
August 9, 1994, A hearing on the matter has been scheduled for
December 21, 1994,
At this time, Plaintiff wishes to update the witness list
set forth in his original Pretrial Memorandum to include the
following witnesses:
Pennsylvania, 17013,
Mr. weibly is the children's maternal
grandfather. He shall testify relative to his relationship with
the children, as well as his relationship to the Petitioner.
2, Ronald Bridge, RD1, Shermansdale, Pennsylvania 17090.
Mr, Bridge will testify relative to the Plaintiff's and his
wife's relationship with the children, their parenting abilities,
the
children's relationship to Plaintiff, and
Plaintiff's
employment history,
1
3, David Myers, Probation Department, CUmberland County
Courthouse,
Mr. Myers will testify relative to Defendant's
husband's criminal record,
Respectfully submitted,
Attorney for Plaint:ff
By <4~~~~
Barbara J! Y is, Esquire
Griffie & Associates
200 North Hanover street
Carlisle, PA 17013
(717) 243-5551
2
DATE:
/;2.d? hsl
~G":Z ~~.
J: Y L BRI
VERIFICATION
I verify that the statements made in the foregoing document
are true and correct, I understand that false statements herein
are made subject to the penalties of 18 Pa.C,S, Section 4904,
relating to unsworn falsification to authorities,
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v.
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNT~, PENNS~LVANIA
NO, 2347 - CIVIL - 1994
JOD~ L, BRIDGE,
Plaintiff
DEBORAH W, BRIDGE,
Defendant
CIVIL ACTION - CUSTODY
PLAINTIFF'S PRE-TRI~L ST~TEMENT
Plaintiff, Jody L. Bridge, files his Pre-Trial Memorandum
pursuant to the Court's Order of August 9, 1994, relative to the
custody hearing presently scheduled for Monday, October 3, 1994:
I. PLAINTIFF'S POSITION
Plaintiff maintains he should have primary physical custody
of the parties' children, Plaintiff has continued to
play an
integral part in the children's lives since the parties separated
in 1988, The parties have acted in accordance with the November
6, 1989 custody Agreement, whereby Defendant maintains primary
physical custody of the children while Plaintiff exercises
partial physical custody of the children every other weekend, In
addition, Plantiff has custody of the children one evening per
week, during the week Plaintiff exercises custody of the children
on the weekend, and two evenings per week during the week
Plaintiff does not exercise such custody, The Plaintiff also
exercises one week during the year of partial physical custody
with the children,
It is submitted that Plaintiff is in a better position to
properly care for the children and provide for their emotional,
as well as their physical, well-being.
It is further submitted
.,,+........,,-.
that Plaintiff has been and continues to be a more positive
influence in the children's lives, Plaintiff is a good
model and and can provide a stable and nurturing environment
the children,
Further, Defendant has continually exhibited an inability to
show appropriate responsibility in caring for the children, as
well as a lack of concern for their welfare, This is most
clearly exhibited by Defendant's choice in personal relationships
which adversely affect the children,
For the above reasons, Plantiff maintains and he should have
primary physical custody of the children for it is in the
children's best interest,
role
for
II, WITNESSES
The Plaintiff plans to call the following witnesses:
a. Jody L, Bridge: The Plaintiff will testify on his own
behalf relative to his care of the children and his ongoing
involvement in the children's care, particularly relative to
their emotional and physical well-being as well as their
schooling, His testimony will also include statements concerning
Defendant's lack of concern for the children's well-being and
Defendant's inappropriate conduct around the children,
b, Lisa Bridge: Plantiff's wife, Lisa Bridge will testify
to the Plaintiff's appropriate relationship with his children and
the very strong and appropriate relationship she maintains with
the parties' children. She will also indicate the negative
influence that Defendant's conduct has shown to the children,
c, Barry and Cathy Ginder, 255 Garristown Road, York Haven,
Pennsylvania: Mr, and Mrs, Ginder, who are friends of the
Plaintiff, will confirm the ongoing positive relationship between
the children and Plaintiff, as well as the ongoing positive
relationship between Lisa Bridge and the children,
d, stephen Gantz, 1405 Boiling springs Road, Carlisle,
Pennsylvania: Mr, Gantz, who is a friend of Plaintiff, will
testify to the positive and appropriate actions of the Plaintiff
when the children are in Plantiff's care, as well as the positive
influence that Plaintiff's conduct has on the children,
e, Rick Paxton, 27 East South Street, Carlisle,
Pennsylvania: Mr, Paxton, who is a childhood friend of Plaintiff,
will testify as to Plaintiff's positive relationship with the
children and how the children are influenced by Plaintiff. Mr,
Paxton will also testify to the positive and appropriate
relationship Lisa Bridge maintains with the parties' children,
f, Larry and Deborah Weibley, 204 Kutz Road, Carlisle,
Pennsylvania: Mr, Weibley is Defendant's brother, He and his
wife will testify on behalf of Plaintiff as to the appropriate
relationship Plantiff maintains with the parties' children. They
will also indicate the negative influence the Defendant's
conduct, as well as Defendant's personal relationships, have had,
and continue to have, on the children,
g. Sharon Chizar, Middlesex Elementary School, 250
Middlesex Road, Carlisle, Pennsylvania: Ms, Chizar
kindergarten teacher who taught the parties' son, Brice, last
North
is a
year in school, Ms, Chizar will testify regarding Brice's
academic performance, as well as what she observed of Brice in
the classroom setting, Additionally, Ms, Chizar will testify
regarding her interaction with both Plantiff and Defendant.
h, Donna Pletcher, Middlesex Elementary school, 250 North
Middlesex Road, Carlisle, Pennsylvania: Ms, Pletcher is a first
grade teacher, She taught the parties' son, Kale, during the 1993-
1994 schoolyear and is currently teaching Brice. Ms, Pletcher will
testify regarding Kale's academic performance, as well as her
observations of Kale in the classroom setting. Additionally, Ms,
Pletcher will testify as to her interaction with Plantiff and
Defendant,
j, Jacqueline Granite, Middlesex Elementary School, 250
North Middlesex Road, Carlisle, Pennsylvania: Ms. Granite is a
guidance counselor at Middlesex Elementary School and also works
for Stevens Mental Health Center. Ms. Granite has been
counseling the children over the past two years, She will
testify as to her meetings with the children and her interaction
with Plaintiff and Defendant,
k, Nancy Small, Franco Psychological Associates, 26 State
Avenue, carlisle, Pennsylvania: Ms. Small is the independent
counselor or therapist secured by the parties to present the
Court a statement of her recommendation concerning the best
interest of the children in this action, As the therapist has
not prepared her final opinion at the time of preparation of this
document, her actual position is unknown.
l, Chuck shapley, 205-A Bernheisel Bridge Road, Carlisle,
Pennsylvania: Mr. Shapley coached the parties' children, He will
testify in regard to how the children interacted with Plaintiff
and Defendant,
m,
Mil ton
stackfield,
Claremont
Road,
Carlisle,
Pennsylvania: Mr, Stackfield is Defendant's husband. He will be
questioned regarding his background, including his criminal
history as well as his relationship with the Defendant, and the
parties' children,
The Plaintiff respectfully reserves the right to call
additional witnesses, particularly rebuttal witnesses, depending
on the position taken by the Defendant and her listing of
witnesses,
Respectfully submitted,
GRIFFIE & ASSOCIATES
Attorneys for Plaintiff
By
", liz'
/" . I '
. II" r ",'tl ". ( ( (~#L~.1
Barbara J/ Yunis, Esquire
200 North Hanover Street
carlisle, PA 17013
(717) 243-555l
._:..&..J.:..:..'.'
VERIFICATION
I verify that the staterents made in the foregoing document
are true and correct, I understand that false statements herein
are made subject to the penalties of 18 Pa,C,S, Section 4904,
relating to unsworn falsification to authorities,
DATE:
Cltl/1'/
~b-~I ~ .~~/~ ~
} DY L BRIDGE
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
,
,
v.
: NO, 2347 - CIVIL - 1994
.
.
DEBORAH W, BRIDGE,
Defendant
,
,
: CIVIL ACTION - CUSTODY
PLAINTIFF'S PRE-TRIAL STATEMENT
Plaintiff, Jody L. Bridge, files his Pre-Trial Memorandum
pursuant to the Court's Order of August 9, 1994, relative to the
custody hearing presently scheduled for Monday, October 3, 1994:
I. PLAINTIFF'S POSITION
Plaintiff maintains he should have primary physical custody
of the parties' children, Plaintiff has continued to
play an
integral part in the children's lives since the parties separated
in 1988. The parties have acted in accordance with the November
6, 1989 Custody Agreement, whereby Defendant maintains primary
physical custody of the children while Plaintiff exercises
partial physical custody of the children every other weekend. In
addition, Plantiff has custody of the children one evening per
week, during the week Plaintiff exercises custody of the children
on the weekend, and two evenings per week during the week
Plaintiff does not exercise such custody, The Plaintiff also
exercises one week during the year of partial physical custody
with the children,
It is submitted that Plaintiff is in a better position to
properly care for the children and provide for their emotional,
as well as their physical, well-being.
It is further submitted
-_.
that Plaintiff has been and continues to be a more positive
influence in the children's lives. Plaintiff is a good
model and and can provide a stable and nurturing environment
the children,
Further, Defendant has continually exhibited an inability to
show appropriate responsibility in caring for the children, as
well as a lack of concern for their welfare, This is most
clearly exhibited by' Defendant's choice in personal relationships
which adversely affect the children,
For the above reasons, Plantiff maintains and he should have
primary physical custody of the children for it is in the
children's best interest,
role
for
XX, WITNESSES
The Plaintiff plans to call the following witnesses:
a, Jody L, Bridge: The Plaintiff will testify on his own
behalf relative to his care of the children and his ongoing
involvement in the children's care, particularly relative to
their emotional and physical well-being as well as their
schooling. His testimony will also in~lude statements concerning
Defendant's lack of concern for the children's well-being and
Defendant's inappropriate conduct around the children,
b, Lisa Bridge: Plantiff's wife, Lisa Bridge will testify
to the Plaintiff's appropriate relationship with his children and
the very strong and appropriate relationship she maintains with
the parties' children, She will also indicate the negative
influence that Defendant's conduct has shown to the children,
~
c, Barry and Cathy Ginder, 255 Garristown Road, York Haven,
Pennsylvania: Mr, and Mrs, Ginder, who are friends of the
Plaintiff, will confirm the ongoing positive relationship between
the children and Plaintiff, as well as the ongoing positive
relationship between Lisa Bridge and the children,
d, Stephen Gantz, 1405 Boiling Springs Road, Carlisle,
Pennsylvania: Mr, Gantz, who is a friend of Plaintiff, will
testify to the positive and appropriate actions of the Plaintiff
when the children are in Plantiff's care, as well as the posit~ve
influence that Plaintiff's conduct has on the children,
e, Rick Paxton, 27 East South Street, Carlisle,
Pennsylvania: Mr. Paxton, who is a childhood friend of Plaintiff,
will testify as to Plaintiff's positive relationship with the
children and how the children are influenced by Plaintiff. Mr.
Paxton will also testify to the positive and appropriate
relationship Lisa Bridge maintains with the parties' children,
f, Larry and Deborah Weibley, 204 Kutz Road, Carlisle,
Pennsylvania: Mr, Weibley is Defendant's brother. He and his
wife will testify on behalf of Plaintiff as to the appropriate
relationship Plantiff maintains with the parties' children, They
will also indicate the negative influence the Defendant's
conduct, as well as Defendant's personal relationships, have had,
and continue to have, on the children.
g, Sharon Chizar, Middlesex Elementary school, 250
Middlesex Road, CarliSle, Pennsylvania: Ms, Chizar
kindergarten teacher who taught the parties' son, Brice,
North
is a
last
year in school, Ms. Chizar will testify regarding Brice's
academic performance, as well as what she observed of Brice in
the classroom setting, Additionally, Ms, Chizar will testify
regarding her interaction with both Plantiff and Defendant,
h, Donna Pletcher, Middlesex Elementary School, 250 North
Middlesex Road, Carlisle, Pennsylvania: Ms, Pletcher is a first
grade teacher. She taught the parties' son, Kale, during the 1993-
1994 schoolyear and is currently teaching Brice, Ms, Pletcher will
testify regarding Kale's academic performance, as well as her
observations of Kale in the classroom setting. Additionally, Ms.
Pletcher will testify as to her interaction with Plantiff and
Defendant,
j, Jacqueline Granite, Middlesex Elementary School, 250
North Middlesex Road, Carlisle, Pennsylvania: Ms, Granite is a
guidance counselor at Middlesex Elementary School and also works
for Stevens Mental Health Center. Ms. Granite has been
counseling the children over the past two years, She will
testify as to her meetings with the children and her interaction
with Plaintiff and Defendant.
k, Nancy Small, Franco Psychological Associates, 26 State
Avenue, Carlisle, Pennsylvania: Ms, Small is the independent
counselor or therapist secured by the parties to present the
Court a statement of her recommendation concerning the best
interest of the children in this action, As the therapist has
not prepared her final opinion at the time of preparation of this
document, her actual position is unknown,
l, Chuck Shapley, 205-A Bernheisel Bridge Road, Carlisle,
Pennsylvania: Mr, Shapley coached the parties' children. He will
testify in regard to how the children interacted with Plaintiff
and Defendant.
m,
Mil ton
Stackfield,
Claremont
Road,
Carlisle,
Pennsylvania: Mr, Stackfield is Defendant's husband. He will be
questioned regarding his background, including his criminal
history as well as his relationship with the Defendant, and the
parties' children.
The Plaintiff respectfully reserves the right to call
additional witnesses, particularly rebuttal witnesses, depending
on the position taken by the Defendant and her listing of
witnesses,
Respectfully submitted,
GRIFFIE & ASSOCIATES
Attorneys for Plaintiff
By
"", /1 ~.~.
:,{ ,- / /1 (
/It (-.fr'~.J ',-,rlL-1
Barbara,J, Yunis, Esqu re
200 North Hanover Street
Carlisle, PA l7013
(717) 243-5551
VERIFICATION
I verify that the statements made in the foreqoinq document
are true and correct. I understand that false statements herein
are made subject to the penalties of 18 Pa,C,S, section 4904,
relating to unsworn falsification to authorities.
DATE: CJ 1-:).1 / f"/
7 I
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CIIILD STUDY TEAM REFERRAL
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Couns..llng
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Spp..ch/Languag.. Scr....nlng
Statement nf Cnnc..rn: Attach any stud..nt pap..rs that may bp p..rtln..nt,
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CUMBERLAND VAI.LEY SCIIOO!. OISTRICT
Child Study T~am Report
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BUlldlng: ~~.(~
Date of Child Study Team Meeting:
Date of Birth: 9-..< j-F7
.
Grade: I
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aye each person sign)
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preSe~ing Problem: ,
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To ~~ comPfleted ~f psychological evaluation is requested
1st o. quest lOpS to be answered, .
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CUMBERLAND VALLEY SCHOOL DISTRICT
Child Study Team Report
Student Name: ~U~. ~/L../.;'f"_
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Building: "~,1;.f~/lf~J~
Date of Child Study Team Heeting:
Date of Birth: ?-.J1-1'7
Grade: ~t'~.I~~_~
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Preaen~ng Problem:
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1985 EDITION
SIT
~O~~~
SlOSSON INTELLIGENCE TEST
INDIVIDUAL TEST FORM
Name ~y / ~ ~jk-_
l.A~1 ./
Ri~ard L, Slollon. M,A.
,
7'2 l {. (-<
..M~'
Test Rllsults:
ChronologIcal Age (CA) ""',"'"
Mental Age (MAl, .. .. , , , ' , , .. - .. ,
Intelligence Ouotient (10) """".
Percentile Rank (PR),.",."...",
Normal Curve Equivalent (NCE), ,. .
Stanine Category. , , , , , . , , . , , , , .' ,
T-score , , , . , , , , . , , , , , , , . . , , , , , . . .
"',(JOll
~
/f(.;
,-
Address
School'tJenCy I}JL//tt. {':'u '<
Sex -If.t- Grade
Referred 8y
Examiner
Finding the MA
Basal Age -
IJUST BEFORE FIRST EJJROR1
Added months I
(QUESTIONS PASSED
AFTER BASAL AGEl
?'?R 1 :53
Z2 MONTH 17
VE~ MO'2~TH /D2-AV
Chronological Age:. 11..... -
YEAR MQ TH DAY"
-when USing Nonns T.bI... th. n*WnUfft CA tS 2 "... Ind """ ~ 1. ytln.
-If ttlt numb.. at dl'fl IICItM 15. tonSldtr ..,full month andina'latthl months byont.
Date of Test:
Date of Birth:
!/ -/ 'i
MA - - 1
I'
-
CONVERTING 1-12 ~-~~ j.8-1 111-1211
YEARS :!.2-1 5. tin ~-gn 11-1:12
TO MONTHS: 3-36 ti.72 9-lll~ 12'IH
1:1-156 lti.1!J2 19.22tJ 22.26-1 25-:100
U-16~ 17.20-1 20-2-10 2:1.276 26-:112
15'1~1l 1~'216 21-252 2-1.288 27-324
1/2 MON11t'S CREDIT I MDN11t I S CREDI T 2 MDN11t' S CREDI T 3 MONTH'S CREDIT
Yeu. and aonth. Year. and .onth. Years and .on tho Yeu. and aon th.
0-0,5 1-0,0 ~ ~ -5-0 g-O 13-0 16-0 22-0
o-t. 0 1-0. 5 ..-2:.l ...=S:.2 -U 13-2 16-3 22-3
o-t. 5 I-\.O ---l:l +11-2 ' .d::z.i ~ 13-4 16-6 22-6
0- 2. 0 I-t. 5 ~ - 4-3 _5-6 ~ 13-6 16-9 22-9
~~ 1-2,0 ~ .:J-t-4 -+-5- 6 ~ 13-8 17-0 23-0
0-3.0 1-2, 5 ~ ~ -5-10 9-10 13-10 17-3 23-3
0-3,5 1-3.0 2-6 -h-6 -to-o 10-0 14-0 17-6 23-6
0-4,0 1-3.5 2-7 -/1-7 +6-2 10-2 14-2 17-9 23-9
0-4,5 1-4,0 2-8 -4-8 -6-4 10-4 14-4 18-0 24-0
0-5,0 1-4.5 2-9 -k-g -6-6 10-6 14-6 18-3 24-3
0-5,5 1-5,0 2-10 -4-10 ::!-6-8 10-8 14-8 18-6 24-6
0-6.0 1-5, 5 2-1\ -4-11 -6-10 10-10 14-10 18-9 24-9
0-8,5 1-6,0 3-0 -=h-O 1\-0 15-0 19-0 25-0
0-7,0 1-6,5 3-1 -2 11-2 15-2 19-3 25-3
0-7,5 1-7.0 3-2 -7-4 11-4 15-4 19-6 25-6
0-8.0 1-7,5 3-3 '-1-6 1\-6 15-6 19-9 25-9
0-8.5 1-8,0 3-4 -7-8 1\-8 15-8 :10-0 26-0
0-9.0 1-8.5 ~ -7-10 11-10 15-10 :10-3 26-3
0-9,5 1-9.0 ..:::l:tl -s-O 12-0 :10-6 26-6
0-10.0 1-9.5 i -8.2 12-2 :10-9 26-9
0-10.5 1-10,0 -8-4 12-4 21-0 27-0
0-1\,0 1-10, 5 -8-6 12-6 21-3
0-1\.5 1-1\.0 .-8-8 12-8 21-6
1- II. 5 +3-1\ -8-10 12-10 21-9
1/2 X_ = I X S = ..s=- 2 X t, - /;)., 3 X -
- -
'0 1984 SIonon EduCi\llonal PublicatIOns. Ine
All RIQhlS Rest!rlo't!ll
Addition.l COQieJ Av.il.b1.., From
SLOSSON EOUCATlONAL PUBLICATIONS, INC,
P.O Box 180. East Aurora. New York 14052
~
.
;.:
it
j
,.
Light's Retention Scale
RevIsed Edition
H, Wayne Light
Name~,...i Ce.; 6'(i~ e., Date5!,;J.J fq3
Date of Birth ~ Age: yr,.5 mo, B Grade Y
School M, dcl.ttS-t.'IL Teacher S ~ Guts non
DIRECTIONS: This scale is to be used as an aid in deciding whether or not a udent should be retained,
Read each item and circle the number following the most accurate statement. Interpretation of each area
and the total score is found in the Light's Retenrion Scale Manual. II is of great importance to read the manual
before making interpretations and conclusions, This scale is a counseling tool and should not be considered
a psychometric instrument.
1. SelC of Student
Student is a boy in kindergarten through third grade, , , . . , . , , , , , . , , , , , , , , , . , , , , , , , . , , , .(Q)
Student is a girl in kindergarten through third grade .."'""""""..""""...",,., 2
Student is a boy in fourth through twelfth grade, , , , , , , , . , , , , , . , , , , , , . , , . , , , , , . , , , , , , , , , 3
Student is a girl in fourth through twelfth grade, , , , , , , , , , , , , , , . , , , , , . , , , , , , . . , , , , , . . , , , ,4
COMMENTS:
2. Studenrs Age
Studen~s birthday falls in the last half of the calendar year and is in the younger half of his
or her present class, , , , , . . , , , , , . , , , , . , , , , , , , , , , . , , , , , . , , , , , , , , , , , , , , , , , , , , . , , , ,G)
Studen~s birthday falls in the first half of the calendar year and is in the older half of his or
her present class , , . , . , , , . , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , . , , , , , , . . . , , , . , , , ,2
Student is one year older than the students in his or her present class, , , , , . , . , , , , , . , , , , , , , , , 4
Student is more than one year older than the students in his or her present class, . . , , . , , . , , , . . 5
COMMENTS:
3. Knowledge of English Language
Student has good communication skills using the English language ,.."""""""""", 0 7
Student has limited use of the English language but is acquiring new skills quickly, , , , , , , , . , , , (j)
Student has little or no knowledge of the English language and is not acquiring new skills. , , , , , , 5
COMMENTS:
4. Physical Size
Student is significantly smaller than others the same age, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 0
Student is slightly smaller than most others the same age, , , , , , , , , . , , . , , , , , , . , , , , , , , , , , , ,CD
Student is the same physical size as most others the same age, , . , , , , , , , , . , , , , , , , , , , , , , , , . , 4
Student is significantly larger than others the same age .", , , . , , , , . . , . , , , , , , . , , , , . . , , . , , , 5
COMMENTS:
Score. Page 1 ~
Copyrighr 0 by H, Wayne Ughr. Ph,D.. 198/. 1986
All naN'lW'Wf\I'fd HoPltl oIltwt fftotd Ionn ",",yt.1f1)l'Oduct"d ," ,nyform 01 P""II"IDf by ,"yOl"" mHM. f'l<<tronoc or Iftft"""",.al, Il'lth.On.. bull101ltm.tf'd1O. photoc~
"'10 ,~I rKord'''I,nd "''''''''1\101\, ."Cf potI"y,1 or dupllUloOl'I ,n ..ny ''''0t'''''''1Orl "or'....1Id rt'tMft'" ''''tm. ...hauI ,,"","won '" Wftt1"I 'I'OI"II"~.
J1cademic Therapy Publicarions. 20 Commercial Boulevard. Novaro. CA 94949-6/9/, Reorder No, 277.5
S. Present Grade Placement
Student is in kindergarten, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , . ,(2)
Student is in first grade ,,""',""""',',',',',',""",' , , , , , , , . , , , , , , , , , , , , . " 1
Student is in second or third grade, , , , , , , , , , , , ' , , , , , , , , , , , , , ' , , , . , , , . , , , , , , , , , , , , , , , 2
Student is in fourth to sixth grade, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , " 3
Student is in seventh to twelfth grade """"""""""""""",."..""""",,4
COMMENTS:
6. Previous Grade Retentions
Student has never been retained and started kindergarten by age five """"",..,.""., @
Student has been held out of kindergarten and started school one year later than
other children his or her age , , , , , , . , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , . , . . . . . . , , , , . , 3
Student has had one or more grade retentions, , , , , , , , , , , , , , , , , , , , , , , , . , , , , , , , , , , , . , , , , S
COMMENTS:
7. Siblings
Circle only the highest number that applies.
Student has no brothers or sisters, , . , , , , , , , , , , , , . , , , , , , , , , , , , , , , , , , , , , , . . , , , , , . , , . , , 0
Student has a brother or sister more than three grade levels above or below student's
present grade level, , , , , , , , , , , , . , , , , , , , , , , , , , , , ' , , , , , , , , ' , , , , , , , , , , , , , . , , , , . , , , 2
Student has a brother or sister two grade levels above or below present grade level, , , , , , , , , . , . 3
Student has a brother or sister one grade level above student's present grade level "".""" @
Student has a brother or sister at the same grade level or one grade level below student's
present grade level """ , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ' , , , , , , , , . , , , , , , , , , . , 5
COMMENTS:
8. Parents' School Participation
Parents attend school conferences and are actively involved in school activities ,. , , , , , , , . , , . @
Parents attend teacher conferences but rarely are involved in other school activities, , , , , , , , , , , 2
Parents attend very few teacher conferences, , , , , , , , , , , , , , , , . , , , , , , , , , , . , , , , , . , . , . , , , , 3
Parents never attend teacher conferences , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , . . , , . , , , , , , , , 4
Parents never attend teacher conferences and are not supportive of the school staff, , , , , , , , . , , 5
COMMENTS:
9. Experiential Backgrou nd
Student comes from a background that offers almost no opportunity ior social or
cultural stimulation , , , , , , , , , , , , , , , . , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , . , , 0
Student has minimal experience with the community and has few previous experiences
in non-school activities '" , . , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ' , , , , , , , . , , , , , , , . . , , .Q)
Student has had many enrichment experiences (Le,. summer camp, foreign travel,
church groups, scouts, etc,) , , , , , , , , , , , , . , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , . . , , , . , , , , 4
COMMENTS:
Score. Page 2 ~
..,-......'"
10. Transiency
Student has attended one school since beginning kindergarten """""",.'""""... IOl
Student has auended two or three schools in the past three years. , , , , . , , , , , , , , , , , , , , , , , , , ~
Student has attended four to six schools in the past three years. , , , . , , , , , , , , , , , , , , , , , , , , , , , 4
Student has attended seven or more schools in the past three years. . , , . , , , , , , , , , , , , , , , , . , , S
COMMENTS:
11. School Attendance
Student misses more than 25 days of school in nine months , , , , . , , , , , , , , , , , , , , , , , , . . , , , , , 0
Student misses lIto 24 days of school in nine months ""."""",..."".,."""'.,, 2
Student misses 3 to 10 days of school in nine months """"",'."""""""",'.., ,m
Student misses fewer than 3 days of school in nine months, . , , , , , , , , , , , , , , , , , , , , . , , , , , , , ,Y
COMMENTS:
12. Estimate of Intelligence
Student's intelligence is within the average range (16th to 84th percentile) , , , , , , , , , , , . . , , , , ,,@ ?
Student's intelligence is below average (5th to 15th percentile) , , , , , , , , , , , , , , , , , , , , . , , , , , , , 4
Student's intelligence is above average (85th to 95th percentile) , , , , , , , , , , . , , , , , , , , , , . . , , , , 4
Student's intelligence is significantly below average (below the 5th percentile) ""'.""",,, 5
Student's intelligence is significantly above average (above the 95th percentile) . , . , , , , , , , , , , , , 5
COMMENTS:
13. History of learning Disabilities
Student has been evaluated by an educational psychologist and no learning disabilities
have been found , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , . , , , , , , , , , , , , , , , , , , 0
The teacher sees no evidence of a learning disability, , , , , , , . , , , , , , , , , . , , , , . . , , , , , , , , , , , . 2
The teacher believes the child has a learning disability , , , , , , , , , , , , . , , , , , , , , , , , , , , , , , . , , ,<!)
Student has been evaluated by an educational psychologist and found to have a
learning disability, , , , , , , , , , ' , ' , , , , , , , , , , , , , , , , , , , , , , , , , . , , , . , , , , , , , . , , , , , , , , , , S
?
.
COMMENTS:
14. Present level of Academic Achievement
Student is one year below grade level in all academic areas ,," , , , , , , , . , , , , , , , , , , , . , . , , ,rm '?
Student is more than one year below grade level in all academic areas, , , , , , , , , , . , . , , , , , , , , ,,!
Student is at grade expectancy in one subject area and one year below grade level
in all other areas, , , , , , , , , , , , , , , , , , , , , , , , , , , . , . , , , , , , , , , , , , . . , , , , , , , , , , . , . , , , , , 3
Student is at or above grade expectancy in both reading and spelling, , , , , , , , , , , , , , , , , , , , , , , 4
Student is at or above grade expectancy in all academic areas ""',."""""."..""" 5
COMMENTS:
Score, Page 3
1
'-
15. Studen!'. Allllude About POllible Retention
Student rl'quests retention to "learn what was missed" , , , , , , , , . , , , , , , , , . , , , , , , , , , , , , , . , , ,0 ?
Student seems disinterested In whether he or she should be retained or not, , , , , , , , , , , , , , , , . (D
Student requesh retention but insists that he or she get the same teacher next year, , , . , . , . , , , , 3
Student dKrl'eS tu retl'ntlon only after parent persuasion , , , , , . , , . , , , , , , , , , , , , . , , , , , . , , . . . 3
Studl'nt dill'S not w.mt retention but agrees that he is behind in his school work '" , , , , , , , , , , , 4
Aftl'r dppropriate counseling by the teacher or parent. the child remains upset if the
subject of rt'tl'nllon IS .1Pproached """""""""""""""""",'.'",..,. 5
COMMENTS:
16. Motivation to Complete School Tasks
Studl'nt spl'nds at least 80 percent of class time working on school assignments, even
thouKh soml' may be too difficult '""'"""",'.'"",."""""""",,'.,,,. 0
Studl'nt works on those tasks that he or she is interested in , , , . , , , , , , . , , , , . , , . . , , . . . , , , , , . 1 )
Student is disintereslt'd in school but will work if encouraged, , , , , , , , , , , . , , . , , , . , , . , , , , , ..Q) .
Student is disinterested in school and needs one.to,one encouragement to
complete assiKnments , , , , , , , , , , , . , , . , , , , , , , , , , , , , , , , . . , , , , , , , , , , , , , , , , , . , . , , , , 4
Student will avoid school related tasks (within child's academic achievement level) even
when offered individual help "'""",."""""""""""."."."""",., 5
COMMENTS:
17. Immature Behavior
Student associates with children two years or more younger than his or her actual age, , , , , , , , ,0 ?
Stud'!nt associ.ltes with children one year younger than his or her actual age, , , , , , , , , , , . , , , , ,3 .
Student associates with children his or her age """""""""""""",."...,." (j)
Student associates with children older than his or her age """""",."""",..,.....)(
COMMENTS:
18. Emotional Problems
Student dues not exhibit behavior sometimes seen in emotionally disturbed children (i.e,. is
not distractible, depressed, overactive, nervous, cries often, etc,) , , , , , , , , , , , . , , , , . . , , , , CV
Student exhibits behavior sometimes seen in emotionally disturbed children (i.e,. may be
distractible, depressed. overactive, nervous, cries often, etc,) , , , , , , , , , , , , , , , , , , , , . , , , , 5
COMMENTS:
19. History of Delinquency
Student has no history of antisocial behavior, , , , , , , , , , , , , , , , , , , , , , , , , , , . , , , , , , , , , , , , , , 0
Studl'nt occasionally has difficulty following school rules , , , , , , , , , , , , , , , , , , , , ' , , , , , , , , , , ,(!)
Studl'nt often has problems on the playground and in the classroom , , , , , , , , , , , , , , , , . , , , , , , 3
Student has a history of discipline problems in the classroom, playground, and community,
but has not had contact with law enforcement, , , , , , , , , , , , , , , , , . , , , , , , , , , , , , , , , , , . . , 4
Student has a history of discipline problems in the classroom, playground, and community,
and has had contact with law enforcement, , , , , , , , , , , , , , , , , , , , . , , . , , , , , , , , , , , , , . , , . 5
COMMENTS:
Jd-/utut&.r, ,&,ftU;Uk.
Score, Page 4
/0
~!
TOTAL SCORE
,'(',S Edition
DIAL--R'~
RECORD BOOKLET
Carol Mardell.Czudnowski
Dorothea S, Goldenberg
Developmentallndlcalors lor the Assessment 01 Learning-Revised
Child's Name 7jrit!.b 13r!d;~
,
Nickname
Address
/ ~,'{ b
(./' ~r'I'IJ1. '); I N
0'"8oy OGin
Phone Number
Mothe(s Name
Child's Primary Language
s..:r~en''''Q 0.11e
VfAf~ '-'GNTH o...~
J"..:! <.{
",' ;r
'! f
$" ..:>
. ,
"~L
I ~'
__a_
B,,"hO,lle
ChronOlOqlCdl AQ@
SCORE SUMMARY
SC.1I00
SCOfe
TOlals
MOlor ..23
Concepts ~~
"".:
Language ,:)6
DIAL R f01a1 7~
Paler-Ilal
P'COI~m
DeCISion', .
POlenT'JI
OK Aavatlcoo
. Use aAIoIlI ku>d In
Ajlpencb E In 1he 1NIIlUlIl,
~~..'-"
o %I,S_deWdlon
o ~,O stancIInl.. '1ISic "
0-
Norm ISn1lIe choeon:
05'nsus
S'" Caucasian
o Ikoonly
u_-._'Jx.~O
;""_/ #0
Ie""........
.y
'\
:.=<.:.:~~.
.
,~
(7.J..~~.'q'
-X
OVERALL SCREENING OECISIOH
Potential
PrClbk!m
I
Potential
OK ~anc&d
1/1 I
~ based on:
!a"'" DIA1..R Total """'"
o 2 au! of 3 area sans
o all 3 area sa>res
o 111M oc:ore
0-
RESULTS FROM OlliER SCREENINGS
Hearing
+
~
Does Itle child need 10 be ""erred lor '--up vision or
heanng lISS8SSmen11 0 No 0 Yes
" yes, chec:k wI1ich: 0 HMnng ~ VIsion
Vision
+
BEHAVIORAL OBSERVATION DECISION
;...::.;~.~:~. :..... '".
.
. -,"
StJm 01 observations ched<ed for aIllhree areas: 0
Doosllle cI1ild need la be ",ferred for Iunher socialIaffecllve .-....$'Tl8l~? 0 No OV8ll'
(5<>6 Appendix E in the manual for artoffs,)
AdditioneI a>mmenls on Itle c:hiId's behavior.
. .
"',
..::"..;
. ":')O'.~ ',' -:
. ._..t.~." ..... .~.
-.
'.
i
:- ~
/
AeS"
- I'll)() A'T'lt'Mcan Gu-d.1ncD Ser.....ce 'f" C.reln p,~s MN ljs.o'" 1;"1)6
.\11 "11M!!; ..."..,......, .~O ;).1,1 ,~, ''''.<; 'Kef'" 000...., "n.h ~ Pt"OIrx::;u.>'('J JI om'!.......''';!' "'''''OIlLl ....
"...,~ "..... J '",.\ ~ J "l . .; .. -I ]
Ordpr ,HlfllU11~.ihHed
MOlar OperJlor's NamH
~
"
MOTOR
SCALED SCORE
0123411em
l.Ildef ScaJed
2~, 2.3~, 3-<1 yrs. 4-5~, !Hi yrs, Salres
~
r
f
1. Catching 0
2. Jumping, Hopping, and
Skipping 0
jumps: 0 (])
hops: (nght) 0 1 2 3 4 sQ
(left) 0 I 2 3 4 5 ~
skips:, .
O--other:~ 2.step;hop or gallop 3.sk.1P
3. Building 4-r.::.~+""~ 0
. .-. ,r--.]#~'
.. '.. ..\ ,..
.,'9 ,!9 (..
4. Toucbing F,:lngers .," . '
Ctt,,U...C::A::O,' '-7"4 u Va a
5. Cutting -+s4 d. ~4-l<I--j
6. Matching 0
+
-
o
~
-
:tt
.L
~
o
-
S
-
I 0
- -
Lli
-
-
7, Copying 0
I 0 1 0 E 0 (92
o 0 02 N @1 2
+ 0 1 €> 0 &)1 2
o 062 S<Q)12
~ @>1 2 :tt 002
~ @)12 ~ 002
8, Writing Name ~ ~ 0
BEHA~ORALOBSERVAnONS
(Checf< aI thai """",)
unable to separate from adult
crieslwhines
""",lUng 10 ~ quoslIons
pllfSOYOOlIive; repoaIs what she or
he says or does
distrac1tio: does not pay ~n..,1Ion
2
, 2
1-2 3.8
2
1 I 2
1~7 \ 3
!
I
I
1.7
112-1a 19.24
,
+
12
r:.
'- -- I
. ,
.. ". "
Scaled Score Toml
,(max,.31)
o
Jt,per;Idiw: r8Clless; fidgety;
'antsy'
roeisliv8; unwIIIIno 10 try tasks
cisNpIMt; InIerrupts testing
proc:8cUos ,
Sum ol Mo4or observatlclnl
c!\u..hacI - .
~
2
o
~3
I
I
" I
,
,
__ ---'__ - ______ ~ ____.1
\ ~,r',~I" I' :1" I" I ,:1 "I"J
Concepts Operator,;; Name
CONCEPTS
1. Identifying Body Parts
..!'.~ ..nedl.... .<:l!llL
Jlau:-- ~tnm:lr.h shoulder
l:ill... !InlllL. chest
-l!I.lll!l. ~ hiiet
lOngue elbow wnst
ankle
hop
waist
2, Naming Colors
~~~@@.!..@@~
3, Counting (Rote) f,t;
I 4. Counting (Meaningful)
1 @5 7 9
5'~,ositi~n.!ml.. /'~ ~
E!')!!.,?,J ~ ~ ~
6. Identifying Concepts
~ bog
j)cL.
~
_.n~~L
langesl long
~ more
JaSIp.st last
.l1II1es.L Irttle
cold
!Wi
..Q~
shortest short
least less
slowest slow
-
7. Naming Letters
OBPERWYG
8, Sorting Chips
By color: cB) ~J G
By sIZe @ (r~
By shape: @
BEHAVIORAL OBSERVATIONS
(Chocl< .11 that apply,)
unable 10 separate Irom adult
crleslWhines
UllWllting to answer questions
perseveratiYe; repealS whal she or
he says or does
distractible; does nol pay attention
o
under
2)'B,
SCALED SCORE
1 2 3
4
IIem
ScaIlld
2.3 yrs, 3~ yrs, 4-5 yrs, 5-6 yrs, Scllres
o
?
'--'
1,9
10-1
; 16-18
0 1.7
0.2 '1 -:=:L
--- i
0 I 3 5-7 9 I
I
0 1.2 3 4
I
0 1.14115.2
0 ,
- ,
i
0 - ,
I
Scaled Score Tolal
(max,.31)
hyperactive; ros1tess; fodge1y;
'antsy'
resislive; ullWllUng 10 try tasl<s
disruptive; inlenupls l8Sting
ptOC8dures
o = Concepts observations
I
'~
3
Qrch.l( oIdrl1lflISft~red
Language Operator's Name u__,________._u
~mii'
~ , ' .
go 10 hOSP'I"y'a.~ / CJ ~_(, , .'~ ;l!J I '
. W.""'t' "
o ~1.2 3.4
LANGUAGE
1, Ar!iculatlng
';-
~/ !~! yu~
bed chalf \ dre5~
CUP. " "11110..... ... ;..;;"Cti.....
cT~~', ~~ jj;';mb -
...~and' fish . ;;'~ee~
2. Giving Personal Data
-,.... LL.J.'-f
lirsf name';~ ',.yx ~cv phono number
last namoC",...~tieet /
3ge S CIty/stale J LJd ~~}l
3. Remembering "" /'
dappong: ~ B C
numbe,s: ABC
-
ABC
--
sentences:
.-., ."
~... ,1"
J '
4, Naming Nouns
~'~
~ ,~~'
5. ~m,i':'9.'. Vfl.rbs7
~' f9.u2-
(lE) F'l,n-:'
(~ ~
6, Classifying Foods
Tally 11-\4 \ \I
'7. Problem Solving A'l2
hungry "O,J.. 1 V
__dUL
dar1( r~ 0:, 1 0 "
I '(jl' u ../1
~ I . ~~./ .... . " .
rain:, . 0 1 2 .:.... /'..
_I .J ,; "... W..- ,- " I'
broken: r/ ~O; cD 2. I"
8. Sei~(~~g;~~/~/~
~
<B!Od[)
(liiil&j~
BEHAVIORAL OBSERVATIONS
(Chod< aJllhat apply,)
unable to separate from adun
Ctles/wtunes
ullWllling to answer questions
P<!1S<lV8rn1ive; repeals whal she 01
he says 01 does .
dlstrac1Jble: does nol pay attention
o
undor
2 yrs,
o
,./
l
I
1.3
;
I
I I
11.151 16 17
I
o
o
o
,.9
o
2.3
,
i'-,!
(oo..J ..:L...
,
,'-, ' It",.
. r-(,..L/ ...N._)
o :
1.2
3
4
Scaled Score Total
(max, . 31)
i
;).,I(J !
, I
, I
I
I
hyperactive: resdoss; fidlleIy;
'antsy'
resistive; Unwi/Ung to by Iasl<s
disruptive; interrupts testing
procedures
o
Sum of language obGeIvaIlons , ',' .
ched<ed i
.- -===---'
4
0-. __ .........._
~.~.,..,..
~ FE E.:H.' :.....~;'3._..~ ;::
~?C~:=E.:::; ~::::CF7
Teacher:'7;?ro. 8l).ruti..
SC:JC /~ldtltlfd.'
Cat e V"{jf;;/.e.,
~ffi
~ame: )(tC.h." t:5r,.i;;u
Grade: /
Your child has been
the area(s) of:
/' Articulation
~LangUage
L Fluency
receiving Speech/Language Support in
Voice
Listening/Auditory Skills
Progress: 1Il.r'f lfoOcL
Comments/Recommendat ions: Ilrf>'t!..n ~d h'n-> ./hJ..4~ O~ .bvnCl..L.A..$~
. . () -----a- r ~ d'
~J1dJ~ Vn-fl/lOvcA ~.d1/ 7Ju-~r.4()~..J..htli-h.>nh'nu.v Iv &.
d'ff'c..NU l,r 'KpI4~/Jn flu- /,.../ ~ you.lhc... /r/. iI" .Iv ~I '1Jf-I:.
~iIJVl/l'/1A/" t,r -:l-h"'J~ - .'J~u........A.... /J-trlr/Itf &n'il J";jrl A2Ki..U7 t'~ rod..
,b?7 ~a"f-lJr"d. '-:0'1,1 l.(,."-r.J-...tI/'~',,r"/J. .}j..rzwA'I'?'rKJ ~::f..~""~d ~J~:J ~
~ ar,'(l fl!. /I u -M h" 0; /.11"; l '1 .I.A.L/1 ih M':I' / .An I- )'1/./), A.... // h?7 (! ~ .L.ueLL
,b?z "aI-ru.t1.fu..~ alj-; J/I'-h'~, r/l,iS fu-dz...v- ~ n~ ..Ji'1d.l-./u-- k
}///~ vu-b4 a-nc:i.. #u:U- lu- t!Rn.hn~ <I-v I::u- d;1f:-..unU=.. ~
"tJICL Gf you have comments/questions, please call me at t~~:3~ti . J
~'n~ +0 Ku- JWtl/l-oLL C(,U-hOLi c.A ~ docfv r ./u:::c.- ~ ~
, / -'0 L
""'fJrorun~r'/.t. V1V.Ju.., Or'l,MJ U vor'Ctl.- Y.l/1 {;f;r, ~ t(...?'-<!Lvavl~
~PP',...t ~ .&-nh'/'lu.-L .bn:fo
'u. /'i'1t!-?s,.<U..I~ ~' 'fr!r.>, ""1ntulOod
Speech/Language Sup?ort
SPEECH/LANGUAGE PROGRESS REPORT
Name: 'K~ dr"~
Grade: I
School: 7;'l.iddb/Je~
Date: If / I'/'il/
Teacher:~/~. ~/~
Your child has been
the area(s) of:
~rticulation
~Language
~FlUenCy
receiving Speech/Language Support in
Voice
Listening/Auditory Skills
Progress: deed.-
comments/Recommendations: f::Ah~\S arb'c,ula/-,'(,)? ~
'&""Jl.LA-r/~~l/~ ~~Y~~'d~7 ~.
....":j-~ b-nI-.vn/J~.. h r-~./'I-~..L4.,h:. k~,
qj e-- LA /)' h.l c... ~ M d. ~ - A-9?-?I'JIJ.J/, ~ zh' n t..U? tL.4
,
~ k .Jv~d-zLy /Jf-rt.(C!.:h~ "lj~~U_
])/~}{I/"u"nA'/AA i"'~h"-",, a..-nrL /nfl.rrt~n~ ~AiJO.....L.
,,6Mrr'~,..b?V ~-t.?7:;rh"~(.~ a.-6h''''-I'h'es.
dt/q -5'S'P~
If you have comments/questions, please call me at h97--;J3h:J-.
t/Va>>-e- ~ ~ ha..cJG b -IIu..- j)n.I. -fv .~
~ ~-~AA~ ~O/l./ VO,~/?'Wd.~l<? ? #~
VOu.h~ ~ 6L..hoar~.
~. '11w-ft.aal
Speech/Language sup~ort
"'6 ~ll 'd... ..l../ KL. -k ~~ )Ii I f..L ..I::u-- .tUNU'b I)~, .
~ Tht..L~d~ ApriL /~H. dur/')f -f/a-u-7z.:C~lj.J,
X REEVALUATION _IEPAEVlEWON..Y
SUMMARY OF ELIGIBILITY AND PROGRAMMING:
THE MDE RECOMMENDS THAT THIS PERSON IS X EXCEPTIONAL NOT EXCEPTIONAL
CHECK ALL THAT APPLY: _ EMRfTMR _ LD XSPL
_ Autism/POD _ DeaflHl _ Multihandicapped _ OHI SED
_ Blind NI _ Dav Delay NI _ PH _ Gifted
MDE PROGRAM RECOMMENDATION: (circle)
Instructional Group(sb I % 2 ] Lev~ Intervention
(LS ES GS LSS ~ . . . Q.1lJ RR PT FT)
S P L Middlesex
(Wg) DATE OF EXPECTED
Location INmATION DURATION
j/11....Jditl.50C f/l/~/r;1 "/ I'i /'1','
81 193 61 194
. i
CUMBERLAND VALLEY SCHOOL DISTRICT
MULTIDISCIPLINARY EVALUATION REPORT
INDIVIDUALIZED EDUCATION PROGRAM COVER
Name:
Kale Bridge
Dale Of Birth 86/04/07
School: Middlesex
class of
2004
REASON FOR MDE: INITIAL EVALUATION
PARTICIPANTS:
CIRCLE If p,.a.nt(p) or conaulted(C)
INmAL Ag.... or Do Not Ag.... tor both MDE and IE
(PARENT IS REQUESTING PRE HEARING IF THEY DO NOT AGREE)
MDEDATE: // II 41 ~ '1
MULTIOISCIPUNARY TEAM
RECOMMENDATION
Agee 00 Not Agee
PC
SUIert Kale Bridge
lJ. ~ I-Cu\r. t ~ ~!\..U-\ o.
ParentIs) Deborah W, Bridge ,
PC ch...-b
PC
~
(jc )('711/
~/
rj}-4-
.', . /
. /7
P'c.. I :r:
PC
File No. 9170
SSN:
179664226
IEP DAlE: if I, '71 q:r
IEP CONFERENCE
PARTICIPATION
Agree 00 Not Agl1Hl
PC
pcd~
PC
.
r@jL>
(~cfrJ1J
~~
~~>
" ./
P~- ,/'/1"
'-' -
PC
REOCM.eO:DEVAWA'11Ot& _1b1e _ Retest
IEP CONFERENCE SUMMARY:
LOCATION of IEP CONFERENCE:
Date MDT/lEP INVITATION was sent home:
Dale IEPiTIIORA was sent home: -/rwA
INFORMATION FOR PARENTS (check):
81,94 61 196
~ Pf,r,...t l~ UJ'l~/~/rr willnrmlljl
I-o.t: ../' 0CKXl. lELEPHONE
111'I1C,3 -
~ given to parents
fJ/'enOu,j/.'
CVSD 6 pI
not needed
......."
e erfdge
SUMMARY OF FINDINGS:
PRESENT LEVELS OF EDUCATIONAL PERFORMANCE
Significant historical Intormatlon and strengths and needs denved Irom educational assessments. parental input.
medical and other documents,
Individual Psychological Examination: FS Date:
PRESENT LEVELS OF SPEECH LANGUAGE PERFORMANCE
Oral Motor Status
Structures/functions are adequate for speech purposes.
Speech Language AnalysIs
Articulation s~ll Is have Improved. At this time, kale has
errors only on the /1 ,r! sounds and vocaliC Ir/.
Spontaneous speecn rate is rapid and results in Whole-word
ana part-time repetition. Intelllglbillty is poor,
especlalty wnen tne tOP1C of conversation is not previously
~nown. Kal~ often speaks out of turn and Inserts fillers,
SUCh as Mum. um, um" In order to hold the listener's
atter.tl,;]n.
Language comprehension skills are imprOVing. He is able to
answer many Wh- questlons and follow directions.
Kale's vOlce has been hoarse since the beginning of school
and he often loses hiS voice during brief conversations.
kale's classroom teacher states that he "1 ikes to
participate verbally," bLlt that she often has trouble
unoerstanding him. She feels that Vale is "making fine
academiC crogress.ll
EClLlcatlonal Implli:ations
Speecn/language Clelays may have a negative effect on kale's
aOll Ity to acequately express thoughtS/Ideas.
CONCLLISIuNS ~Ni) RECOMMENOATIONS TO IEP TEAM
Sceecn,Language Sucport snould continue. Soeclflc goals and
aDJeCtives Will be determined by the IEP planning team. A
re~erral to an Ear. Nose. Throat SpeCial ist Should be
c~nsl~ered In or~er ~o aetermlne tne cause of ~.ale/s
nUCo.r"seness.
CUMBERLAND VALLEY SCHOOL DISTRICT
CVSD-8 SPL
NAME: Kale &rldge
GOAL AREA: Speech/Language
DATE P~EPARED: ~f1Jlf~
DATE ACHIEVED: ___1___1___
ANNUAL GOALS: To increase artIculatIon skills
To Increase fluency skills
To maIntaIn age-approprIate language skIlls
OE:.]ECTl....E: 1
w1l1 ceacie
sentences :;.j:;
DATE INITIATED:~;L1-/~
:~ correctly produce 111 In all
tjf the tIme.
DATE ACHIEVED: 1___1___
posItions of words in
'jf:JECTI....E::: DATE HIITIATED:jLJli./ 'i3 DATE ACHIEVED:___I___I___
wll; be ~ole to estaol Ish a fluent pattern of speech In sentences and
orlef cor.o/ersat Ions 90:; of the tIme.
C&JECiIVE: J DATE INITIATED:1L-IL1-/~ DATE ACHIEVED:___I___I___
WIll oe aoJe to demonstrate maIntenance of age-approprIate language
comorehenSlon/e:<preSSlon skills at all tImes.
PROCEDURES FOR EVALUATION:
___I. SubJect Acnlevement
-!-::. InstructIonal Assessment
-f-J. DIrect ObservatIon
-!-4. Teacher Judgement
___5. StandardIzed Testing
___0. Other
EVALUATION SCHEDULE: MIdpOInt and annual revIew of current IEP.
SPECIALLf DESIGNED INSTRUCTION
The speech and language cliniCIan WIll provide:
Small group instruction
Cueinglprompting
Home practice program
ConsultatIon/collaboratIon
Ol/a/by rQ/ckd g;~Ued
(N4(, CuliJle Pike. Mech4nicJb..r" PIJ, /70"
P"~ (7/7) (97-8161
PARENT NOTIPIGATION
MULTIDISGIPLINARY EVALUATION/REEVALUATION MEETING
Dear
])ehOrW1 nr1riS-L
Nallle of Parent (5) "
A/7vpmb.-r
DOte
~ /n.9
Re:~/(J. 8r,'~
.,'
DEvaluation
~ Reevoluation
Your child has baen referred for a Multidisciplinary Evaluetl<><6Raeveluat~oi1)of educetlonel stetus. As pert of
the evaluotion/reevaluation process. we aro requesting 0 meeting with you os the parent/guardian/surrogate parent
and/or student. the professionals who hove conducted the evoluation. and other knowledgeable persons. The nomes
ot the meeting participants ore listed below. During this moeting, the results of the evaluations will be
reviewed and discussed. Reccmnendotion will be made 05 to ..hether or not yo.H child 15, or continues to be, on
exceptional student and In need at special education programs and services. Recommendations tor the student's
educatlonel programming will elso be presented. The results of this evaluation/reevaluation will be Included In
e Multidisciplinary Eveluetlon/Reevaluatlon Report which will be drafted during the meeting.
Your participation In this meeting Is Important. It will give you the opportunity to provide those In attendance
with your opinions end Insights. The meeting has been scheduled for /=F;,..fIJj; A/aVo /9 /t;q,:J
et d:OO . You may decide not to partlclpete In the Multldl fpl'lnary Evel.fatlon/Reeveluatlon
......t Ing. It you do not respond to this letter within ten 1101 days, the _tlng .111 be held In your absence.
of Meeting Participants
Position
Within twenty (20) school days following the MultidiSCiplinary Ev.luatlon/Reevaluetlon meeting, en Indlvlduellzed
Education Progr.m (IEPI planning meeting will be held to review .nd discuss the Multidisciplinary
Evaluetion/Reevaluation Report. It the IEP planning team decides that your child is. or continues to be,
exceptional and in need of special education programs and services. an IEP ..ill be developed/revised tameet your
child's identified educ8t!onllll needs. YOJr participetion in this meeting ",ill be requested. Yoo will receive
notlflcetlon of the d.te end time for this meeting following completion of the Multldlsclplinery
Evaluetlon/Reev.luetlon process. You..y elect to miv.II the tla> period bet_ the ItIltldlsclpllnery
EvaluatlonfReovaluatlon ......tlng end the lEPplennlng._tlngand. ~8lIu~sLthe IEE-plllnnlnQ meeting be held
i~lately._.iier the MuUldlsc.1plln.ry Evelu~t~LR!".~alu.tlon meet~,--T!>.1s o~tlon c.qnblnes the two meetings
Into one. (It you went the _tlngs to be held together, pl....""_no~_!.hls.on the bott.. of this fo....1
-....---.. .... ..' -~ ..._- -----
~WIII partlclp.te In the Multidisciplinary Evaluation/Reevaluation ,.eetlng. -.-.
_ 'Additionally, 1 would llke the lEP Plennlng _tlng to _Ietely follow the ItI1tldlsclpllnery
EveluatlonfReoveluatlon _tlng.1 I understand that I will not have a typewritten ccpy of the
Multidisciplinary Ev.luetlon/Raevaluatlon report prior to the IEP Planning Meeting. I understend
that this letter will serve as a notice of the IEP Planning Meeting.
1 will not pertlclpate In the Multldlsclpllanry Eveluatlon/Reeveluatlon meeting.
Parent's Signature -11., t:rwo J.... /'1) ~ /dtfL Date 1/-I/-q.,3
Pl....se ",",plete this form and return all copies except IE!!! to: LynnfL !I1.tl..JvJo1
~jI ~/ LaIJ.jUtLf- /1lfI.o/O~ist or telephone cJtjiJ - s:sg(.. to conf I..... the eppolntllent.
CVSD-S
Page 1 of 1
~
,
,
\
3undezbd I:-'I/~ r(;?/~ Q)~~
6?46 Carlule Pike, Mechanu:sburr, Pa, 170"
Phorw (717) 697-816/
REQUEST FOR PSYCHOLOGICAL TESTING
Student's Name ~J / eo Nt" I rI:J -e
Counselor r era..., fe- School /1..dd/~.reo ~
L. 80 v.J~,..s, s/'- Pq,.rJ,olo'J' sr
Type of Referral:
Initial Handicapped
Initial Gifted
--.X... Inilial SpeechlLanguage
Retesl
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(The bottom sechon will be completed by Ihe Pupil Service Office and the torm returned 10 you)
Psychologist Assigned:
------ Dr, Martin
Ms, Caslelt
I,U,
Date Assigned
,-/J.r/; >
Date MDE must be completed
Other comments
ceeun~el/a,d (-t~ rt2/doo/ (~id~
6l4IJ Cd,lul. P,k., Mtc"""'Clbu". Pd, /10" P~oru (717) 697-816/
MULTIDISCIPLINARY COMPREHENSIVE EVALUATION REPORT
A. Student OemoareDhlc Inlormellon
Name
Kale Bridge
Sex M
Student Social Security" 179. 66 _ 4226
Birth Dale 4-7-86
School
Middlesex
Teacher Hrs. Pletcher
Grade I
Ethnic Background:
x
American Indian or Alaskan
Black, nol Hispanic Origin
While, not Hispanic Origin
Aslan/Pacllfc Islander
Hispanic
Other
Student Address
1226 Claremont Road
Carlisle, PA 17013
ParenVGuardian
Deborah W. Bridge
Parent Address (II dlllere"l)
Home Phone 258-1721
Work Phone
243-3335
B. R.e.on lor R.I.rrel
Relerred by L. Bowers
Position S/L Pathologist Phone
Reason lor Relerral
Kale is experiencing academic difficulties. These
are expected to be S/L related.
CVS[)..l
Psgs 1 01 2
STUDENT NAME Kalc BridRC
C. EDUCATIONAL, SOCIAL AND PHYSICAL HISTORY
Year Grade/AssiQnment
1993-94 1
Suooort PromamlSftl'\licAs
SchooVAQencv
Middlesex
Possible S/L Support
Achievement Tests: N .A.
Name of Test
.l2Wg
Scores
Intelligence Tests:
Name of Test
Datll
Individual
Group
Instructional Levels: Reading
P.
FS.
Current communication skills Articulation errors noted. Difficulties
with expressive & receptive language skills.
Specific behaviors or difficulties in the classroom that interfere with learning
Kale is having difficulty with academics in 1st grade. He does not
understand what is being asked.
Medical History: (include illnesses/surgeries)
Nothing significant.
Other significant medical inlormation:
None
CVSD-l
Page2of2
L/1/a/4y, Q/~ (c;7)~
~': -
\!;
'",
f.
Ii:,;
~
6l~ a.riillc Pike, MecMniaI""c, Pa. 170" Phone (7ln tR7-8261
;
MULTIDISCIPLINARY EVALUATION CONSENT NOTICE
NAME:~_/t? ,Rr,dje
Date of Request: /.+ -/ - '?;>
DOB _~I' ,<ll ; " /1- L'~ LL._Li.J-)Lc
Social Security ,
Grade:.1.-Teacher: JY]..< f'/~+r ~ l'-"-
sent Class Location:,;+j;..IJ/.:> c;:...)(
.
linary (MD) Evaluation
,,/-1
To help determine needs in educational programming, your consent is required to
aluate the above-named student. The MD evaluation team will include yourself, the
udent's current teacher, a certified school psychologist, and other appropriate school
rsonnel familiar with the student.
Proposed areas for evaluation are indicated below. Refer to the back of this page
further explanations of each area. If additional assessments are recommended during
MD evaluation process, you will be contacted to discuss them. ~hen necessary, you
asked to sign an additional consent form.
l. Intellectual/Academic Ability
2. Educational Achievement
3. Social Adjustment/Personality
4. Communication (Speech and Language)
5. Perceptual/Motor Skills
6. Ecological/Life Skills
7. Vision and/or Hearing
6, Neurodevelopment
9. ~ork/Vocational
10, Other (Specific)
You have the right to inspect and revic~ all relevant school records concerning the
cudent. You have the right to meet with a member of the multidisciplinAry evaluation
eam to discuss the referral and proposed evaluation procedures. You have the right to
ive or withhold consent for the evaluation. You may object to the evaluation and request
due process hearing.
The evaluation will be completed within 45 school days after the school receives
consent.
() II L1 I give my consent (or the MD evaluation as noted above
(tnit ial)
I do ~ give 'my consent for the MO evaluation as noted above
(Initial)
~ork Phone
this form and/or direct questions to:
Title
Phone ,
Notice of Procedural Safeguards
Page l of l
(See Back)
.... . ""~.-
- ~. ......
.,':.~~
." "'~
ceunder/evu/ IJI4~ r(;?/~ (q;UJ~
6746 Canul. PIk., M.chanlClbur" Pa, 170"
Plu"". (7/7) (f}7 -826/
PARENT/GUARDIAN REPORT
Student ~/ e- fir.. d J Q.. DOB L\. -,- ~~l t
As part of the Multidisciplinary Evaluation/Reevaluation process, we ask that you provide us
with information and opinions that will be helpful in identifying your child's educational needs
and preparing recommendations to meet these needs,
Please return this form to L, R/'l III t> r ~ by / d- - 10 - 9..J. Thank you.
,
A, Instructional/Academics:
Strengths/Concerns
l\ah QJli~C\.f '\.UJ..L~'1 (L,lc\
\ \ l' ''''", " ,~
- - \......L. '-...., ~/l
.'
B. Communication Skills: (spoken and written language)
Strengths/Concerns
fu-Ll lLL0 \\Lli...'-l \C ~~~.I..~,"-,'\:~_\.l~+ ltl,"" CcQLw.Y t '-.J,(O+>
illCb ~~.\~C:',\.L\.z "'.\.lo..l.t 'Ui...~\.....(.l. (, '-"l.~( 'i.....J,2cc'l. '!"-C.Le.. C.:.... ~
C. Behavioral: \.lOr)(1 -tu l\.\. --t'0 \.:"i. i...,- '-'- x.;. \..""\4, 1,.O,.J.d ,\.L'~o..c( '!J
Strengths/Concerns
J,.<( ~ \, L..... Lit. . .. "' l.' I, <.. C' ,.... " \, .
1)(:'-'-'- '..J '-"..\.~.\ ~X'-\..'-"''- LLI'. \.,'~,-"'I'.J 1.4.\'-'Lu......:-..I.,'-\~
1\ , l' r .. "..... r r ':.' '- . ..' ,\' , : " .'',.:\ " .. , ,
'tl~'S~l~~~~,I,\'~~..~.\. '~:,:-l'-tl ~~~c,~~:; ~~'~, .."'L__.... .r_ '.d-<.-
'"," ..... ,.. ,~~ ') (\.Cl((./ "..) \.i ~'-'--fr"
D, Social: (How oes yo ' r c lid get along with friends and adults) i, I 'I-''Y , . '\'
l...A....-\..-\ 1 _"-'- \ \ .:: ,-J\.. '
Strengths/Concerns
....-\\ C'- 0.-
\,0.\L11
,~, ~L 1,..) ~ (,I..~C'I"C;J
uiil u.l.;,) ,
. \', .. '." ,-I ,_1 \, ' "
l....\..'. "- ~_ h.\...U '(Y) .:\ \.~, . ,l t.
, '
'-
01 \..,,-.,,,
..J
E. Please provide any other information that you feel may be important in identifying your
child's educational needs and planning to meet these needs (I.e" medical, medications,
recent change in the family, atc,)
, )ll \) A () o..l'() \1 C \. u l \:_\.1.<>.:1. i..
<" ,U [i,'
~"1l~ 'n~ ~ ') \.). \1.\\ II\. l \\ \\. , 6
(\J~ u"y.\, \u~ r}.)~
Parent/Guardian Signature I"
CVSD.3 \J'l....Q."-. \'0...... \\.lU\~ \.~ \.U\ ~\.'-~
\\'\...0.., ,'n,'\CJ.,.*Q \:~'\'-6( 'tCN ,
I) 'oj .,
~ \~ 1\ \ J \ ~ (\ \ALd_'lrl ~ L \ l ~ \L\\... ()y){}U-
\9-I'\CQ
Data
I '- 'C(,'\.......t
Page 1 of 1
'-~
C/I/~
((;?/dcd (Wi'4J~
6146 C4rliJle Pike. Mtclullllc,burg. P4, /7055
PhON! (7/7) 697-826/
PARENT NOTIFICATION
KULTIDISGIPLINARY EVALUATION/REEVALUATION MEETING
Dear Of" 1-,,.., ('<> ).,(;',... r-~j' -
Nome ot Parent(s) -
",0'./ _ 7,3
Date
Re:
/G)",_
~ Evaluotlon
o Reevdua tlon
Your child has been referred for a Multidisciplinary Evaluation/Reevaluation of educational .tatus. A. part of
tne evaluation/reevoluotion process. we are requesting 0 meeting with you os the porent/guardlen/surrogate parent
and/or student. the professionals whO hove conducted the evoluation, and other knowledgeable persons. The names
of the meeting participants are listed below. During this meeting. the results of the evaluations will be
reviewed and discussed. RecOlmlendotlon will be mtJde 05 to whether or not YOJr child is. or continues to be. en
exceptional student and In need of special education programs and services. Recommendations for the student's
educational programming will al.o be presented. The results of thl. evaluation/reevaluation will be Included In
a Multidisciplinary Evaluation/Reevaluation Report which will be drafted during the meeting.
Your participation in this meeting Is Important. It will give you the opportunity to provide tho.e In attendance
with your opinions and Insight.. The meeting has been scheduled for S- / / - 9 .?
at 3.'00 ('1") . You may decide not to participate In the Multidisciplinary Evaluation/Reevaluation
meeting. If you do not respond to thl. letter within t.n (lOI day.. the _tlog will be held In your absence.
Names of Meeting Participants
n~ 1s.("a J... R.... d'j e
~ ~ i:L~~<: ;:
P"AI t Ion
r", ..-"",,-1
T"Co<c /, t>,..
~,. fht/""/"yt
,.., '" I' , t"".... I
,
Po.ltlon
Names of Meeting Participants
Within twenty (20) school days following the ~ultldlsclpllnary Evaluation/Reevaluation meeting. an Individualized
Education Program (IEPI planning meeting will be held to review and dlscu.s the Multldl.clpllnary
Evaluation/Reevaluation Report. It the IEP planning team decides that your child is. or continues to be.
exceptiono 1 and in need of spec io 1 edUClIIt Ion progrems and Serv lees, an IEP wi 11 be deveLoped/rev ised ta meet your
child's identified educationnL needs. Your participation in this meeting will be requested. You will receive
notification of the date and time for this meeting following completion of the Multidisciplinary
EvaluatiOn/Reevaluation proces.. You...y elect to ....Ive the t~ period bet_n the "'Itldl.clpllnary
Ev.luationfRBev.luatlon _tlng and the IEP planning _tlng and reque.t the IEP planning meeting ba held
immediately atter the Multidisciplinary Evaluation/Reevaluation meeting_ This option combines the two meetings
Into one. I If you ....nt the _tlng. to be held together. pl....se noto thl. on the bottooo of this fOI"ll.)
_____ I will participete in the Multidisciplinary Eveluetion/Reeveluetion meeting.
~ltlonallY. I would llke the IEP Planning _tlng to _iately follow the "'ltldlsclpllnary
EvaluatlonfReovaluation .uetlng.) I understend thet I will not heve e typewritten copy ot the
Multidisciplinary Evaluation/Reevaluation report prior to the IEP Planning .....etlng. I understand
thet this letter will serve es e notice ot the IEP Plenning Meeting.
I will not participate In the Multldisclplianry Evaluation/Reevaluation meeting.
pt.."",
~:..
Parent's Signeture
Date
Pi..... complete th Is form and r.turn all copies except II!!!!! to:
or te lephone
to confirm the appointment.
CVSD-S
Page 1 of l
''AJo.'.,....
6146 Carli>l. Pak., Mechanu:,burll, Pa, 170"
Ph,- (7/7) fJ}7-8Z61
STAFF REPORT FOR THE MDE
Evaluator
Student
Kale Bridges
Dr. Har~aret S. Hartin
Date of Evaluation
May 28, 1993
Psychologist
Title
Summary 01 Findings:
K4le is experiencing academic difficulties. He has may articulation problems
and has demonstrated difficulties in both receptive and expressive language.
Whatever his problems with language, he certainly does not have any
personality problems. He is physically at tractive, blonde, blue-eyed and delight-
fully loquacious. He chatted constantly telling charming tales of mountains and
beach and his plans for the summer. There was intermittent verbal mutilation, but
he was oblivious to this and sailed right along even with a detailed description of
his grandparents' black and white dog that was "shaggy and he is not a
dalmatian."
Recommendations:
Of the children I've seen this year, Kale appears most likely to have need of
perfect speech and even with his rather minor errors, there is obviously great
potential there. Throughout he was so totally pleasant that one can almost envy
Hrs. Bowers as she works with him in the coming months.
Enroll in S/L to the maximum the clinician feels indicated.
CVSD-3A
Page 1 011
:., .:.' . wo.... -.'
...... - .. ~
III - Summary of Recommendations to the Individualized Education Planning
Heeting Participants
Kale Bridae
has demonstrated the folLowing needs and strengths.
!!!!!!! :
To improve articulation
Therapy for language comprehension
Strengths:
Pleasant young man
Tries hard to please
Recommendations:
~ The results of the Multidisciplinary Evaluation indicate that he/she
meets the diagnostic criteria to be identified as a child/student with
Spep,.h 1T."nq""qp di ff ; cuI t ie~nd is in need of special education
programs and services.
---- The results of the Hultidisciplinary Reevaluation indicate that he/she
continues to be exceptional and is in need of special education
programs and services.
The results of the Multidisciplinary Evaluation/Reevaluation indicate that
he/she does not meet the diagnostic criteria to be identified as exceptional.
Louise E. Bowers. M.S. CCC-SLP
EvaIuation Chairperson
5-11-93
Date
CVSD-IA
Page 2 of 3
NOTICE OP RECOMMENDED ASSIGKKENT
Student ~ j t"' iff" I dj -e. Data
Dear /},,!; Bf','dj e..-
S- / /- 9..3
?5und~ C://'a&;y Q/~ q)I4Nd
6746 C"rlu(t Plkt, MtchanicJb..." p", /;0"
Phoru (717) 697-826/
Durlng the Individualized Education Program (IEP) Planning Meeting. recommendotions were made tor an instructional
pr~.. and placement assignment ~r your child. Tha I.E.P. Team reco nds that your child, presently n
lie.ve /12P .....,,....7"'-/ / r baJ!!Alad/contlnueel In
This Dsslgn~nt wos recommended after a review of the attached Option Form to OS
services that will meet your child's needs. As a parent. you hoye certoin
Notice of Procedural Setequords. Please cor.tully reod the information in
need further explanatIon, pleose contact Cumberland Volley's Supervisor 0'
Services at 697-8261.
1.
-X-
Your chlld should begin to receive special eelUCllUon progr_Ing es Includeel In the IEP (IEP attached).
The school district will not proceed without your approval of this recommendation.
2.
Your child's special eelucatlon placament. progr_ and/or services should be c"nglld as nateel In the
attachad IEP (IEP attacheel.. Tha school district will procaad with this change within ten lID) school
days of your receipt of this notice unless you do not approve this recommendation.
,.
All current special aducatlon progr.... and services should be discontinued. The school district will
proceed with this change unless you do not approve this recommendation within ten (10) school days of
receiving this notice.
All special education services should be discontinued at the end of the current school year. Your child
Is gr_Ung trom high school .lth a diploma.
Your child should continue in hiS/her present assignment. Your child Is non-exceptional and not in need
of special education. programs, and/or services.
(lh, (;?)!Ib~
School District Superlntandent
DIII:CTIac5:
Please check one of the options bel~, sign this form and return all copies (except gold).
I approve the recommendation.
I do not approve this recommendation.
x ~L~l)~.l(t~
Signa ture
..5-: / / - 9..3
tor disapprovel Is:
If you do not approve the recommendations of the Individualized Education Program Planning Team, you may request on.
at the tollowlO9:
I wish to request: _ prehearin9 conference
meet la t Ion
_____ due process hearing
at 1
CUMBERLAND VALLEY SCHOOL DISTRICT
.~ S,j' -/j 'Ie) f(
,} ~' 3, ~.3 3J' ll/
Child Study Team Report
Student Namc: -i;;~. Y;h~L>
l1 "
Building: '/11Lf./V,/.I
Date of Child Study Team Heeting:
~-1.,--- f3
Datc of Birth: 7'-7-/(,
/
i
(:/Jtt~ !d
...Jrdlv
Grade:
Partic~ants: (Please ,have each person sign)
-!it: ~ .,~ '
" _ ~ k~~ ' ~::,i~)
pre~e~ing Problem:
WUL~e~cifVM II/~Li--'
t
Identifi!!d Problem (If different): . I.' ' -
o1P3/4;t/hC. /Itf fli'Jtr If!. if ~L 13 ~ fJ;\iI f.,2 tfj;.:f 'f/f /R"t-
~Jj/'rf It'S: ' '
:.ftwx"mu ./""ltdlfi<< ~.I! 0.0 ~'.~ "j ~..I '-.,' '""
'It/}(. -fiL....&l..... , kl~4.-!...t.f~LL~~e /t:t!~,4!- j 1Z~ ~a
OptiOllS discussed/tried:f'1.t-i.t:.t~ 01di!.. b-..... ,.u.L-,v/U'/E~. /lItcJtIzix..A....-
~"c..- _ /hu-il
:fft /7{, b ,.~~L--
.
Ex~nuating conditions:
htlPJf-. dtu,rU~_b ,~(.a. /~it~~l)a ~ ,PYK t,e' .i .t~/'';M<_
;&fij; -()Jt./~/_ <<'~~'t~/, " ..." " I tIt.tL1U.{'~- uti fk" , . I
tJ.u.tI'tbRb1-- 4t'",tf; .~fi' ///.d;%;:-;v~ ~
RecolDlDend~,t lon. ,.' ;J-l.tltl~/d!.tCJt!1& 17M 1~( /~';v'a of~,1~/~L
iftlflbt.-j'M. - ,/I"C' L~~tt..~'et:.;: ,U.I!-&u.L- ~(~a..-1h,/71C; .
1~_':.i/IJlJf(X,. .j'..J8-13 II'IYJ ' 'f)LI'W~,?K/ K.9W!~d ~&....~~
v~ '/~h /V/ C' 7'rJ (j
To b~ completed ~f psychol~~~~ion is requested
Llst of questlons to be answered. .
.,.'."", '
'- I~'I. ( /~~ /; "((I;'" L'.l .C'(~' ,& 1;-
Light's Retention Scale
ReVIsed EdItion
H, Wayne lighl
'/ I , I . I
Name ~.., It'. '" r /0 (; e Date 'I, '1 \
Date of Birth.Ltf'/" / 7/ !9g:., Age: yr, '7 mo, I Grade
5<:hool~O>~,( Teacher J1r~ n(J~c.hf:''''
DIRECTIONS: This scale is 10 be used as an aid in deciding whether or not a student should be retained,
Read each item and circle the number following the most accurate statement, Interpretation of each area
and the total score is found in the Light's Retention Scale Manual, It is of great importance to read the manual
before making interpretations and conclusions, This scale is a counseling tool and should not be considered
a psychometric instrumen!.
. ~ -
I '.:i
I
1. Sex of Student
Student is a boy in kindergarten through third grade, , , , , , , , , , , , , , , , , , , , . , , , . , , . , . , . , , , @J
Student is a girl in kindergarten through third grade """""",.,.""'.'""""",,, 2
Student is a boy in fourth through twelfth grade, , , . , , , , , , , .. , . , . , . , , , , , , , . .. , .. , , , , , , . . 3
Student is a girl in fourth through twelfth grade, , , , , , , , , , , , , , , , , . , , , , , .. , , . , , . , , , , , .. , , ,4
COMMENTS:
2. Studenrs Age
Studenrs birthday falls in the last half of the calendar year and is in the younger half of his
or her present class, . . , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , . , , , , , . . , , , , , , , , , , . , , . , , . ,@)
Studenrs birthday falls in the first half of the calendar year and is in the older half of his or
her present class , , , , , , . , , , , , , , , , . , , , " """""",.".""",.""""""".2
Student is one year older than the students in his or her present class, , , , . , . , , , , . , , , , , , , , , , , 4
Student is more than one year older than the students in his or her present class. , , , , , . , , , , , , , 5
COMMENTS:
3. Knowledge of English Language
Student has good communication skills using the English language """"""""..,.", (f)
Student has limited use of the English language but is acquiring new skills quickly, . , , , , , , , . , . . 2
Student has little or no knowledge of the English language and is not acquiring new skills, , , . , , , 5
COMMENTS:
4. Physical Size
Student is significantly smaller than others the same age , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 0
Student !s slightly smalle~ tha~ most others the same age, , , . , , , , , , , , , , , , , , , , , , , , , . , , , , , , (f)
Student IS the same phYSical size as most others the same age, , , , , , , , , , , , , , , , , , , , , . , , , , , , ,Y
Student is significantly larger than others the same age " , , , , , , , , , , , , . , , , , , , , . , , . , , , , , , , , 5
COMMENTS:
Score. Page' ...:<.
Copyright C by H, Wayne light, Ph,O" /9B/, /9B6
An ,..,.,~. Nop'" ~ 'h""KOfdIOff'l "'"., brrttptOdllCf'd ,n .n,IOI'''' ~ ~",,,..Of by "n" 01.... _'"" f'!<<1f0ftl(' 01 """~ftI(.l, '''''IId,n.. blA noIlo""'f'd 10. phorocooY'
'"I. MIO\'l1U,fI ft"Coodonl .Ild ."n"",,,-,. .nd port"'.,., Of duploull()I'I ,n .n, ,ntOf""I"'" \.lOf.'f'.nd ''''on.l ,""..,... ....hou! pItI''''....-. ,n "'n..,..'I'Or"I'.... pub'l~
Academic Therapy Publications, 20 Commercia' Boulevard. Novalo, CA 94949.6/9', Reorder No, 277-5
........ ..
S. Present Grade Placement
Student IS in kindergarten, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , ' , , , , , , , , ' , , , , , , , , , , , , , 'q;O
Student is in iirst grade , , , , , , , , , , , , , , , , . , , , , , , , , , . , , , , , , , , , , , , , , , , , , , , , , , , , , , , , " I
Student is in second or third grade, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , . , , , , , , , , , , ,
Student is in fourth to sixth grade, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , . , , , , , , , , 3
Student is in seventh to twelfth grade """"""""""'"""""""""."",.,,4
COMMENTS:
6. Previous Grade Retentions
Student has never been retained and started kindergarten by age five ',.,'"",.""".,., @
Student has been held out of kindergarten and started school one year later than
other children his or her age, , , , , , . , , , , , , , , , , , , , , , , , , , , , , , , , , , , . , , , , , , , , . , , , , , . , 3
Student has had one or more grade retentions, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , . , , . , , , , , , 5
COMMENTS:
7. Siblings
Circle only the highest number that applies,
Student has no brothers or sisters , , , . , . , , , , , , , , , , , , . . , , , , , , , . . , , , , , , , , , , . , , , , , . , , . , , 0
Student has a brother or sister more than three grade levels above or below studenrs
present grade level, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , . , , , , , , , , , , , , , . , . . , . . , , . , . . , , , 2
Student has a brother or sister two grade levels above or below present grade level, , , , , , , , , , , , 3
Student has a brother or sister one grade level above studenrs present grade level """"'" cD
Student has a brother or sister at the same grade level or one grade level below studenrs ~)
present grade level """"""""""""""""""""""",.""""", 0'
COMMENTS:
/'
-
8. Parents' School Participation
Parents attend school conferences and are actively involved in school activities , , , , , , , , . , , , , . 0
Parents attend teacher conferences but rarely are involved in other school activities, , , , , , , , , , (f)
Parents attend very few teacher conferences, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , . , , 3
Parents never attend teacher conferences , , , , , , , , , , , , , , , , , , , , , ' , , , , , , , , , , , , , , , , , , . , , , 4
Parents never attend teacher conferences and are not supportive of the school staff , , , , , , , , , , . 5
COMMENTS:
9. Experiential Background
Student comes from a background that offers almost no opportunity for social or
cultural stimulation, , , , , , , , , , , , . , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , . , 0
Stu?ent has minimal, ~xperience with the community and has few previous experiences _"'\
In non.school aCllvltres , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , . , , , , , , , , , , . UJ
Student has had many enrichment p.xperiences (i.e,. summer camp, foreign travel.
church groups. scouts, etc,) , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , . , , , . , , , , , , , , 4
COMMENTS:
Score. Page 2 -LL
,
10. Transiency
Student has attended one school since beginning kindergarten """""""""""""'..Q..
Student has attended two or three schools in the past three years, , , , , , , , , , , , , , , , , , , , , , , , , ,(1)
Student has attended four to six schools in the past three years, , . , , , , , . , , , , , . , , , , , , , , , , , , , 4
Student has attended seven or more schools in the past three years , , , , , , , , , , , , , , , , , , , , , , , , S
COMMENTS:
11. School Attendance
Student misses more than 25 days of school in nine months, , , . , , , , , , , , , , , . , , , . , , . , . , . , , , 0
Student misses 11 to 24 days of school in nine months """.",.,."."",."".",.... 2
Student misses 3 to 10 days of school in nine months "",."""""..'""."."".", 3
Student misses fewer than 3 days of school in nine months, , , , , , . , , , , . , , , , . , , , , , , , , , , . , , <3)
COMMENTS:
12. Estimate of Intelligence
Student's intelligence is within the average range (16th to 84th percentile) '. , , , , , , , , , , , , " , ,rQ)
Student's intelligence is below average (5th to 1 Sth percentile) , , , , , , , , , , , , , . , , , , , , . , , , , . . Y
Student's intelligence is above average (85th to 9Sth percentile) , , , . , , . , , , , , , , , , , , , , , . , , , , , 4
Student's intelligence is significantly below average (below the 5th percentile) ",'.""."", 5
Student's intelligence is significantly above average (above the 95th percentile) , , , , . , , , , , , , , . , 5
COMMENTS:
13. History of Learning Disabilities
Student has been evaluated by an educational psychologist and no learning di~bilities
have been found , , , , , , , , , , , , , , , , , , , ' , , , , , , , , , , , , , , . , , , , , , , , , , , , , , , , , , , . , , , , , , 0
The teacher sees no evidence of a learning disability, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , CD
The teacher believes the child has a learning disability "" , , , . , , , , , , , , , , , , , . , , , , , , , . , , , , 4
Student has been evaluated by an educational psychologist and found to have a
learning disability, , , , , , , , , , , , , , , , , , , , , , , , , , . , , , , , , , . , , , , , , . , , , , , , , , , , , , , , , , , , , 5
COMMENTS:
14. Present Level of Academic Achievement
Student is one year below grade level in all academic areas "","',',',","""","" @
Student is more than one year below grade level in all academic areas, , , , , , , , , , , , , , , , , , , , , , 3
Student is at grade expectancy In one subject area and one year below grade level
in all other areas, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , . . 3
Student is at or above grade expectancy in both reading and spelling, , , , , , , , , , , , , , , , , . , , , , , 4
Student is at or above grade expectancy in all academic areas ""',"""",""",""" 5
COMMENTS:
Score. Page 3--1--
-."...-...
15. Student's Attitude About Possible Retention
Student requestsretention to 'Iearn what was missed" , . , . , , , , , , , , , , , . , , , , , , , , , . , , . , , , , , , 0
Student seems disinterested in whether he or she should be retained or not, , , , , , , , , , , , , , , , , a~,
Student requests retention but insists that he or she get the same teacher next year, . , , , . , , , , ., 3
Student agrees to retention only after parent persuasion, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , . " 3
Student does not want retention but agrees that he is behind in his school work .", . , , , . , . . , . 4
After appropriate counseling by the teacher or parent, the child remains upset if the
subject of retention is approached ",.,"""',.,"'",."""",."".",..,.,., 5
COMMENTS:
16. Motivation to Complete School Tasks
Student spends at least 80 percent of class time working on school assignments, even
though some may be too difficult """"",.,"',."."""",."",...,..,..., (Q)
Student works on those tasks that he or she is interested in , , , , , . , , , . , , , , , , , , . , , . , , , . , , . " 1
Student is disinterested in school but will work if encouraged, , , , , , , . , , , , , , . , . , , , . , . . . , , . . 3
Student is disinterested in school and needs one-ta-one encouragement to
complete assignments, , , . , , , , . , , , , , . , , , , , , , . , , , , , , , , , , , , , . , , , , , , , , , , , , , . , , , . ., 4
Student will avoid school related tasks (within child's academic achievement level) even
when offered individual help """""""",.".,."."."".".,.",.,.."", 5
COMMENTS:
17. Immature Behavior
Student associates with children two years or more younger than his or her actual age , , , . , . . , , 0
Student associates with children one year younger than his or her actual age, , , , . , , . , , . . , , , , . 3
Student associates with children his or her age "'."".,.,',.,',.,..".,',.,",.,"',@
Student associates with children older than his or her age ,.",.",."..""",.""""..4
COMMENTS:
18. Emotional Problems
Student does not exhibit behavior sometimes seen in emotionally disturbed children (i.e,. is 0-
not distractible. depressed, overactive. nervous, cries often, etc,) , , , , , , , , , , , , , , . , , , , , , . \.V
Student exhibits behavior sometimes seen in emotionally disturbed children (i.e,. may be
distractible, depressed. overactive. nervous, cries often. etc,) , , , , , , , , , , . , , , , , . , , . , , , , , 5
COMMENTS:
19. History of Delinquency
Student has no history of antisocial behavior, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , . , . , , , , , , ,@
Student occasionally has difficulty following school rules , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , 1
Student oiten has problems on the playground and in the classroom , , , , , , , , , , , , , , , , , , , , , , , 3
Student has a history of discipline problems in the classroom, playground, and community,
but has not had contact with law enforcement, , , , , , , , , , , , , , , , , , , , , , , , , , , , , . , , , , , , , , 4
Student has a history of discipline problems in the classroom, playground, and community,
and has had contact with law enforcement, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , . , 5
COMMENTS:
Score. Page 4
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u
TOTAL SCORE
.:1F
, "
CL~BERL^~D VALLEY SCHOOL DrS:RICT
Child Study Team Report
~' ,
Student Name: ' . t)."uf',;,'
.J . v
Building: 1/',./,/I{:I,"
Date of Child Study Team Meeting: .3 -//- f ~
Date of Birth:
Lf - 7-J'?
GrAde: /
Particfpants: (Ple~se have each person sign)
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To b~ completed ~f psychological evaluation is requested. j -/f-1,J attuf -'~ -~
Llst of questlons to be answered. ~~
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NAME
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SCHOOL
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RATED BY
Age :,- -,Ii
:::; -//-7~
DATE
GRADE
RELATIONSHIP TO STODENT
AUEI:TIO:: DE:'I:IT D!SOR!lER 3EP.AVIOR IlAU::C; SCALES PRO?ILE S?:::ET
II f < ~ E ; e ~ 1~liHl~I'I~1 1~1~1~2eFI~2~JF~~
;C~RE
l INA':'TEN1'ION
2 IMi'J..S!J!TY
J HYPE~AC-IUITY
4 AN~ER CONTROL
OJ ACA~~MICS
, 6 f\N.<IETY
., CO~~IOE!'iCE
a flGRE;SIUENESS
'3 RE::;T~"":E
i0 SO::<lL
IIIII1
II II i I
III I
III X
II IIII
I I ~
III I
IIII N
II II X
III II
NORMAL
\1111 II I I I \ lX
III I I I IlX I I II II I
IIIIII ~ III
I II III I IIIIIII
I I I II }~ \ \ II I
I II I I I IIIII
II rx I I I, I 1111 I
I I!! II I III I II I
! I ! : II I I I III \ I
['x I I I I I I I I I I I I I
I'\T RISK
U~RY HIGH R!SK
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Students scorin9 ei9ht or more on Inattention and Impulsivity meet the
behavior criteria for Attention Deficit Disorder without Hyperactivity
and should be referred to their medical doctor for the possibility or
medical intervention,
Students scorin9 eight or more on Inattention, Impulsivity, and
Hyperactivity meet the behavior criteria for Attention Deficit Disorder
with Hyperactivity and should be referred to their medical doctor for the
possibility of medical intervention,
SClClle -A.D,O,- students who are emotionally withdrawn will not meet criteria
for IMpulsivity but should be referred.
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Rate EVERY state~ent :y
fits the student's behav~o~
1 You have not notioe:: this behavior be~o~e .
2 You have notioed this beha'/io~ to a slight c-ag=ee.
3 You have noticed this beha'/ior to a conside=a::le c.ag:-ee.
4 You have noticed this behavior to a la=ge c.a;=ee.
5 You have noticed this behavior to a ve='1 la=:;e cagree.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11-
12.
13.
14.
15.
16,
17.
18,
19.
20.
21-
22.
23.
24.
25.
'~""\ :". .
~.o.o. BEHAVIOR RA~ISC SC~~!S
a~ Ned Cwens ~, !d.
e~::y ~ihi:a C~~~S
AgeL G =ac.e-L Da:e ..:( -/ / - 9'..3
placing the a?~~~p~i~:: ~~~=~:- ~t~:~ :cs:
in the box oppcsite t~e s:ate~ent.
Fails to complete assi9ned tasks.............. .....~ ~
otten acts before tr.inking..............................:.1- :L
Runs or climbs a great deal................................
Gets mad easily..... ~ .. ... . IO...... ....... IO.. .. . . . ...... ........-L .:L
Is a poor reade~.......... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Doesn't seem to listen or ~ay attention............ ~
Shifts excessively f=om one activity to anothe=........ ~
Has difficulty staying seated.............................~ I
Shows anger when told to do something........................._
Is a p.oor spelle:............. IO.............. .....................-1-
Poor concentration on difficult tasks........... ...~ L1
Can't seem to organize school work......... ..... .......-!-
Has difficulty sitting still; fidgets........... ..........~ '
Is easily frustrated...........................................;.l
Does not follow verbal directions.................................~
Doesn't stick to just one play activity-
(changes a lot)................ . . . . . . . . . . . . . . . .. 1
Needs a lot of supervision........................~.~ , ,
Moves excessively curing sleep or "rocks" in cayt.ime......1i-
Loses temper easily... . ..... ............ ... . . . . . ...... ........-1- -:J
Handwriting is poor (may vary day to c.ay)....... ..................~
Is distract.ed easily......................... . . . .. 5
Interrupts or speaks out 0: turn......................~
On the go much of the time................................~ I
Can't take teas inq . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Has difficulty in co~pleting ~omework......................,..::7.~
Jlf- 4- ~O 4- 4-
...,:~. ,H
'R~ee E~E~Y s:aee~ene ~y placi~g e~e a~?ro~ria:~ ~~~=~~ ~n~=~ ~cs:
~i:s en. seud.ne's behavicr in e~e box oppcsiee e~e 5:~:~~ene.
1 ~ou have not noticed this :enavior be!ore.
2 You have noeiced this benavior to 3 slight degr:~,
J You have noticed this behavior to a considera=~~ ~'";ree.
~ You have noticed this behavior to a large degre:,
5 You have noticed this behavior to a very large d~g=ee.
Rated by JI7MUU 19I~Ldt.uJ
Relationship to Child ~~~~
26.
27,
23.
29.
30.
31,
32.
33.
34.
35.
36.
37.
38,
39.
40.
41-
';2.
43.
44.
45.
46.
47,
48,
49.
50,
Is atraid ot many things.,........................ --1- L
Do.sn't trust hims.lf or "downs" himself.......... .... I
D.lights in oth.rs' failures or geeting into t==~ble......___
.Exhibits stubbornness........................... .. ... . .. ...... e1.. c::..
Has -I don't care II attitude~......................................:::..!.-
worri.s about many thinqs..,.................... ..-L-
s..ms satisti.d with poor school work............. ....~
Pushes or shoves classmat.s..................... .......... I
Resists b.ing disciplin.d........... . . . . . . . . . . . . . . . . . . . . . .:-::.-L ,/
Is untruthtul and may cheat ae ga~es............ ..................-L-
Is easily .mbarrass.d.,..,..................... ...~ il'
Doesn't compete with others.................... . ......~
'rrie.. to boss other children..........,.,..,. . . . . . . . . . . . .. I
Blames others tor his mistakes or behavior.,..........,...:-::.-L- ..
Mak.. promises but doesn't keep them........... ...................~
Appears hervous............ . . . . . ~ . . . . . . . . . . . . . . . . .--L
Is easily trustrated and qives up quickly....... ...,.. ~
Kakes d.rogatory remarks abou: oeners....... ... ...........-L-
Kust have his own way....... . . . . . , , . . . . . . . . . . . . , . . . . . . . . . . . . . . --1- I
Steal.. . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .......l-
Appears tense................... . . . . . . . . . . . . . . . . . . ~
Has little contid.nce.................................-1- 1
Plays tricks on oth.rs or teases............... . . . . . . . . . ...A "
Will not taka .U99..tiQns.................................::7.~ I
COe. not respect autharlty..........................................L.-
.
(;
6
.Jl..JL1
7 8 9
!O
10.
.
ADD
. . . .'.~
.. .. .,..... ,
. ."".,.4toi",..............~..._~:.
Pa<)o1 2
oC'1.L .L.L:JJ. ~ J. J. V 1 ~ 1.1 ~ r 1 \..i 11 U 1 ~ U.lt1.J .I!I.lt~
EVALUATION SCALE
Stephen B. McCarney, Ed.D.
I
I SCHOOL VERSION RATING FORM 114'~ L.(~~t
,t/u.; .:Jaiux.
,d.:..c "-
Sex:1L
,
Name of Student:~ t'f~Y ,
uut?
School: N, dc/If' ~~:{
;~te.
'l~, (middle'
City: (la r /1 s I t'
..3
II
(day)
7.3
(rear)
State:
1/
(yoan) (monlluo)
,PA
Age:
IE->
Grade level:
/
Date(s) or Rating:
(month)
Has Student Ever Received Special EducatioD Services:
,10
Grades RePe<ed: non e.
Rated by: .:J)o/?n(; pie Ie: he r
Student Known to Rater. St!pf, jl(ar,
(from) (to)
Reason (it known):
\>
Position:
Length or Time Each Day With Student:
Haw Well the Student is Known by the Rater (indicate type or interactions):
I I ./
PROFILE
SUBSCALES
SIaDdaed Perc:eDUI. P.n:eDUI.
ScorH Inattentive Impulsive Hyperactive Rank
20 . . 100 .
19 . . 9~ .
18 . . 90
17 . . 8~
16 . . 80
I~ . . 7~
14 . . 70
13 . . 6~
12 . . 60
II . . ~~
10 .. .. -- ~o
9 . 4~
8 . . 40
7 . . ~
6 . --......
~ . 2~ .
4 . 20 .
3 I~ .
2 10 .
1 ~ .
0 0 .
Copyright 0 1989
Hawthorne Educational Services
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VISUAL PERCEPTION TEST
SCORING SHEET
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'<fName'
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",:',' Address
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--' ," ::Birthdate
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CA
PA
PO
Ra\N Score
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4~'ri,.P"~~'J.!5.;.-
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REASON FOR REFERRAL
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EXlmpl. A B C EXlmpl1 B C 0
-
Itlm 1 (AJ B ~ Item 22 B) C 0
2 A B 23 B ~ 0
3 A B -i4- A B D
4 ~~ c € '25" ~ B C 0
5 C 0 26 A ~ C 0
6 0 -ir- ~ B C 0
-7- ~B~ 0 28 A B C 0
.-&- A B @/ 0 ~ A B C 0
-il9- A @ C
31 A B @ 0
Exampll A C 0 '32-- A B 0
Item 9 A 'J C @
10 ~ C
11 B ,k~ EXlmple C 0
~ A B Item 33 C 0
13 A B C 0 ...;M- B &, 0
35 D
Exampll C 36 C 0
A
Item 14 A C 0
15 $ C (])
16 B C 0
1'7 @g 0
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19 A B @ 0
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21 A B C 0
OBSERVATIONS
b{ ~ ~ ~/;7~/M' rfi'~v7t:-~l::& Zy ~ (//1kO
/flu ill ' .
,
,
RECOMMENOATIONS FOR REMEDIATION
Reorder from ACMNmlC Th.,.p'l Publk.r;onl. 20 Commercii I Boul.vard. Novato, Callforni. 94947
~~Ol:,~~OJ~[
19B5 EDITION
SIT
SlOSSON INTELLIGENCE TEST
INDIVIDUAL TEST FORM
Name ~/d~~, '-~.lt
v.~v ~
Address
School/Agency I)), ,;.-(/It./(,-'/
Sex H- Grade
Referred By
Examiner
-"'IOO\.t
Richard L. Slonon. M.A.
Test Results:
Chronological Age (CAI '...""",
Mental Age (MAl, . , . , , , . , , , , . . , , ,
Intelligence Ouotient (101 ."",'..
Percentile Rank (PRI, . , , .. , .. .. , ..
Normal Curve Equivalent (NCEI....
Stanine Category, , .. , , .. , . .. , . ...
T-score ...'....",....",.".,...
fl3
vn
VEA.,
Chronological Age:. b.
YEAR MONTH OAY"
-wh.n US"'Q Narms TatII.s., 1M rnifl.mum CA ts 2 ytn WId nnII' acntb II "....
-It th. numbtf of dlYt PClla 15. com:M1" IS .tull monlh and ina.al the month. bfont.
Basal Age -
(JUST BEFORE FIRS RRQRI
Added months
1.12
2.2-1
3.36
1/2 MONlll'S CREDIT
Years .,d aan tho
0-0,5
0-1. 0
0-1. 5
0- 2. 0
0-2,5
0-3,0
0-3,5
0- 4. 0
0-4.5
0-5,0
0-5,5
0-6.0
0-6,5
0-7,0
0-7,5
0-8,0
0-8,5
O-g,O
0-9,5
0-10.0
0-10.5
0-11,0
0-11.5
1/2 X_ =
1-0,0
1-0,5
1-1.0
1-1. 5
1-2.0
1-2. 5
1-3,0
1- 3.5
1-4,0
1-4,5
1-5,0
1- 5, 5
1-6,0
1-6,5
1-7.0
1-7.5
1-8,0
1-8,5
1-9,0
1-9,5
1-10.0
1-10, 5
1-11,0
1-11.5
22.264 25-300
23.276 26.312
24.288 27.324
3 MONTH'S CREDIT
Years and aonth.
16-0 22-0
16-3 22-3
16-6 22-6
16-9 22-9
17-0 23-0
17-3 23-3
17-6 23-6
17-9 23-9
18-0 24-0
18-3 24-3
18-6 24-6
18-9 24-9
m-o 25-0
19-3 25-3
19"6 25-6
19-9 25-9
:;n,.O 26-0
:>>-3 211-3
:J]-6 211- 6
:J]-9 26-9
21.0 27-0
,
21-3
21-6
21-9
3 X -
-
(QUESTION ASSEO
AFTER BASAL. ACE)
Date of Birth:
MA
4.~8
5.60
j.g.a
8.96
9.IU8
1O.12U
11-1:12
12'1H
1:1,156
U,I68
15.180
16.192
1';.20~
18.216
19-2'~8
20.2~0
21.252
G.i2
MONTH'S CREDIT 2 MONTH'S CREOI T
Year. and aanth. Year. and aanth.
2-0 --tl. -L!! -I-g-O 13-0
2-1 ---i:..l ---Ll li:i 13-2
2-2 ---.i:l ~ -9-4 t3-4
2-3 ~ ~ - 9-6 13-6
2-4 --1:j .:/:.tl -1-9- 8 13-8
2-5 4-5 ~ -g-10 13-10
2-6 4-6 6-0 - 10-0 14-0
2-7 4-7 -/-6-2 - 10-2 14-2
2-8 4-8 m -f'10-4 14-4
2-9 4-9 _10-6 14-6
2-10 4-10 -8 ......10-8 14-8
2-11 4-11 --f1-10 , . -10-10 14-10
3-0 -7-0 --11-0 15-0
3-1 ..:t:1.:l - 11-2 15-2
3- 2 -7-4 -11-4 15-4
3-3 -7-6 -11-6 15-6
3-4 -/--1- 8 -11-8 15-8
3-5 -7-10 -11-10 15-10
3-6 +S-O -12-0
3-7 - 8-2 12-2
3-8 ~ 12-4
3-9 12-6
3-10 ~ 12-8
3-11 12-10
X - 2 X '/ -
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Q 1984 Stosson Educ:tIIon.J1 PubltCJllon" Ine
All RIQhl" R",""'..,fOl1
Additional Copies AVlillb'1 From
SLOSSON EDUCATIONAL PUBLICATIONS, INC,
PO. Box 280. eat Auror.. N~ York '4052
CHILD STUDY TE~~ REFERRAL
Student.. /J-Je., A3hd().e.,
~ ...L )/} -/ 07 . )
Teacher / /tA..J 7:;::'1'~
Grade /
Date ...3 ~ ..3 - YS
Reason for referral: Counseling
~ Ability/Achievement
Speech/Language Screening
Statement of Concern: ~:tach any student papers that may be pertinent.
, ;la.fe,~ ~~,2~-6t7 ,47?a.'~1/ ~~
-??O~~C..UL~4n.L-C-I &.A. .'~ 1/~ na4,.d
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What was the parental rp.s~onse when you contacted them?' '.
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CUMBERLAND VALLEY SCHOOL DLSTRICT
Child Study Team Report
1
Bu ild ing:
Date of Birth: 1-7-%'6
"
Grade: ~J - jSr
Date of Child Study Team Meeting:
b -J', 1.2
Participants: (Please have each person sign)
1/1///..dK/" ~.Ae~:;;~ &~L~'I---
/
"
Presenting Problem:
iL~~u., r~~C--
Ide~~i.ed~;{;;/~i:;-erend ~1' W
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Exten~ati~~ conditions: ,,( 1;'\ /J-/- ,"/ ,- ft'
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,ecoimendat ion:
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To be completed if psychological evaluation is requested.
List of questions to be answered.
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School Year / 1 '1:; - 9../
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Comments I I "',;~ I ' ' ,I Comments is / ' q'
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EDUCATION - MUSIC
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TEACHER COMMENTS
(1st Period):
III f-I,:, -1,"'<-) Ifp/f; ,..:; t1/lll'/lJ, ~11e- fl/'.fJf/'t'':)5
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(2nd PeriodY. Y
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(~rd Period): ~i
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.;."'// ..1, ",...".:-r...,j -'/,.' "':",:"f./':;. iV)..,! /'('1),/,1,'/11';' _
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PLACEMENT FOR NEXT YEAR
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SPEECH/LANGUAGE PROGRESS REPORT
Name: 'K/LlL dr"~
Grade: I
Teacher:~/r.1, ~r~
School: 1I1Jr/r/bAl!..Ip
Date: '1/ "/'11j
Your child has been
the area(s) of:
~rticulation
~Language
,/ Fluency
receiving Speech/Language support in
voice
Listening/Auditory Skills
Progress: ~
Comments/Recommendations: ~~'S arb'UL{p.J-"e)? ~
.I~JL(nr./ ~dl J ~ ~rl "<1/7 /7'2../J'e..ty.
...-:j~ b?-LI-L/n/1/4 h r/./O.;.nLl'/-p/ kt.t~.
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aNt; -s>sP&,
If you have comments/questions, please call me at hQ7-;Ja{,;;J...."
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Jz,i.., "M..- ~AA<rn 7fO/l./ I/O 4? L /?'W~ ? 1/.u
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CUHBF.RL\ND VAl,Ll>Y SClIOOL DISTRICT
6746 Carlisle Pike
Mechanicsburg, Pennsylvania 17055
Non-Promotion Certificate
Briefly stated, our promotional policy is that non-promotion of any child is to be con-
sidered a very serious matter and each child's case is to be considered on its own merits.
The basis for retention should be the confidence and assurance on the part of the teacher
that the child will profit from repeating the grade,
I. Pupil's Name 10/p. Br,' ~.gP.
Latest group IQ (if available)
7 Grade /
Date
1n-/1-?3
Age
Latest individual IQ (if available)
Latest achievement test results (if available): Reading
Math
Previous grade retained (Please check.) K I
Teacher's reason for retention Lrnm(}--l-ur,'~"
'{:I
'<nn~ ~k; I\~.p.on L!elJe.U '
V-e+' ('(.o..~ ~or a.c..e.ctllr-tYl' c. s ' S'
Nolification of ~rincipal
~ Principal notified of possible retention at mid-year,
~ principal notified of retention one month prior to close of school.
2 3
Reo.~ ,on
,d
4
Notification of Parents
~ Parents notified at mid-year.
Mode of contact:
V Conference
Telephone
~arents agreed.
Parents did not agree,
~ Parents notified of definite retention no later than two weeks prior to close
of school.
Mode of contact: ~conference Telephone
Parents agreed. Parents did not agree.
Summary of Conference
besf
Hofhe,
"Y'lt-ne~t O-t
a~reed +0 do
f= e Q.J,;/d,
w~ r fLJa -S I J? 'i-he
in duplicate: l copy to be placed in the child's cUl1U11ative record file
t copy to be given to the building principal
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STUDENT .-&Le f3r,dJe
P/e..tc.her
Buildlll~
S~huol Year 7'01 - '13
/'1,deJlesex
TeJdler
/1rs
2
3
4
ILEVEL , ".( :.l 7
READING U S s- .s
Commen15 ':;0 3.y,'/
SPELLING AI 5 S s-
Comment' i7 If.,
HANDWRITING S S 5 S
Comments
MATHEMATICS N S- A! u
Comments 10 '/0, i
SOCIAL STUDIES S 5 S S
Comments
SCIENCEIHEAL TH S 5 S Sf-
Comment'
WORk' 5 5- 5 5 CONDUCT S S Sr Sr
HARITS
Comment' 1/ If Comments ~I
PHYSICAL ...,.......,'., G ..i....,....... G :'oIUSIC '):1 S ;j\;;~t~\~l~~l~l\~~ S
EDUC A nON
--- -
Commclll' Comment'
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(I~! Period): ffiUb-w ~:C:'ru-M~.:-~ ??~ .c&.a..L. E~::~~"
J,.U, ~ ~.I nL~ ~J(..t: 4.<J 4~ ,~ ,___,_
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(2nd Penod): Jfa.Le,..hew ..a/;~~ ~..-:nu.J...e, , n'-t-o< ~ ,~ .
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(Jrd Period):""'" R:9//~-'(7 ,,.:In?u:... ~ ~'~~~ .
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(4th Period): jV' / ~: . / , I f'.' ,J .../ ..l / ,
0) t7....Lt.... ~r;JW ~.....<~ TI':~~ -4-L ~K_..L./....J 'j; ~
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-'. PLACEMENT FOR NEXT YEAR '.?r./}x.....t....J,
'--..-1 ~ . _/ .
Building / /~ ( r{ CT. ,{ ,'.<i....i /.,i.
m /) ,
Teacher -M ')( ')~1.!:.)!;.JI r /...
Grade
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CUHBERLA:ID V":'LEY SCHOOL DIS7RIC:T
6746 Carlisle Pike
Mechanicsburg.Pennsylvania 17055
Mid-Year Difficulty Report
The purpose of this form is to have some information in writing at the
middle of the school year for those students who appear to have some
difficulty with their school work and for whom there is a possibilitiy
of retention in the present grade.
Pupil's Name1~. '7~ Date r'~~ If?.:f
Age t; Grade / Teacher~..A VI, bjJAJ School ~/!.4.~L,
Parent's Name
Address /.2:l t- f!JA./U.-?'72..-d"n.& yf';-a.d" (l ~~;h ~ jLJCZI/'tJ/3
Please give a brief description of the child's difficulty. Be specific
as to wha areal s) . ~. . J - //1
-~ ~<;f: .AU~~~~' .()INA
J<<LU ~,.(..j~ ~~f'
/JJo.--6l-~ ~~ ~....ca-u~
J~ ~~ ..-k~.--A~.--Zs-~/.A ,,~.
~~~~Jf:;;y/~.-A:j;:ft ?::;,~
Date of parent-teacher con rence to d~scuss the POS~ility of~~ '
retention /- 07/- 9..3 ~/i<<"7'-VxJ~
Summary of this conference: '7)Z;...t~.-<!,
~~~.~-?-~~ /Y~
~dJo ~..x.A~ -A~~ ,/72 _<~./1 t:?'7c7 .
~ ~~~-.yJd.~ ~ ~~~a.~(..{~~
. -;--is I
J/n.-n.~ J! ~ r.<'..hA.J
Teacher
Prepare in duplicate: 1 copy to be placed in the child's cumulative file
1 copy to be given to the building principal
l/92
,
CUMBERlAND VAl.LEY SCHOOL DISTRICT
6746 Carlisle Pike, Hechanicsburg, PA 17D55
Studl.~t 1/ . Date Records,..,
{.J;r:1';' ~ I j Pupil Rep;istration and Assip;nment Form Requested ;({'/'l-1.::J...
Name ~~rGe- J~~~r., (H~dle) Qxr- ~
Birthdate J-f '-1 tlo Place of Birth 0 Q....diSf PA
(Honth) (Day) (Year) -rCity) . (State" 7~ t"
Mailing Address -.l ~\ 0 ~ t 0 ypm~ Co.n~~one ~
(rtl.d
Road, Street, Development C' '-.0 YQ..fYY)I\-\-
Grade _\ 0/ Teacher/Team _pt Ad. JI
Curriculum/Level Locker 1/
School Assigned
School of I.ast Attendance
Address of
Brothers
~I
Father's Name
Soc.Sec. ()
Mother's Name
Soc.Sec. If
Biological Parents Are: Married
People With Whom Living, if Not With Parents
Bus #
37
Soc. Sec. 11
Assigned r - 1.:1...
Da te Bn te red ..9-=-.-..:..9.
Date Withdrawn Lo ~
Sisters
Birthdate
(ju- U~\J.-rr rt ~ ,. ~l ~ .....
(Employer)
\ ~r' Fa;
~ -~
~ '>Y. ~.
pe 0 cup a on
I/"'Divorced
-t' c':< ~
Separated
Il)~
Deceased
Case Worker Assigned
Previous Special Placement, if any L Speech _ LD -7SED _ Gifted DiR
Is Your Child Limited in His/Her Physical Activity? _ Yes _ No If "yes," explain:
List Any Pertinent Health Information Such As Operations, Chronic Illnesses, Visual or
Hearing Defec~, Allergie~, Etc~i__
l ~ ~ 00..... QJ I: :I&2 bo 0 Q
Imnunization St~us: 0 / Completed
Not Completed
Other
The pupil named above is under my custody as parent/guardian. The Cumberland Valley School
District has my permission to request from you, the school the pupil formerly attended, and
that school has my permission to release, all records, including confidential information
and psychological examinations. My signature below is to be considered as the request for
such records to b nt to the Cumberland Val School District.
lD
-5 drx ,~
(Date)
Signature)
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-
U:VEL I
DATE
Ol\uil,."1
U..
Veca
tested vocabula
eo. nlMulo.
uence
... wont
final consonaon
short vowels
inntction
TOTAL TEST SCORE
LEVEL 2
DATE
Dillrict
Use
tested vocabul
cause/cUCC1
-W..
Hnal consonants
shon vowels. Ion 'Jowel
innection
TOTAL TEST SCORE
LEVEL 3
DATE
OisuiC1
U..
V
tested vocabularv
classification
main idealdC1ads
_ 11''''
initial consonant clusters
final consonant di fa hs
Ion vowell
innections
TOTAL TEST SCORE
l!~1T SKII.LS TESTS
I /-./.}. 9.2.
SUIIC1ttd n
Paninl
'i~o'c " 0
8110
8/10
4/\
4/\
1211\
4/\
4/\ 0
4/\
14130 Irs,
i'i.EVEL 4 ...---~_.- . --_._----_.._-~
UNIT I UNIT 2
DATE I 5 ./~' . t! j i
DimlCl ! SUlJltslN Form SUllntN or
~.. I P3\\lna Panm.
~()fC ,/\ 0 S-.:nrt' " 0
VecalMolan KilO 16/:0 I I
(c\lcd vocabulary KIlO i KilO I
.mlnnvrn' 4, \ 1
daniric3tion 41\
eo. . 4/\ 4/\
- orcdictina outcomes 4/\ c.-
ICQucncc 4/\
I.lItnDra 4/\
reality/fantasv 4/\ C- o. "
...W...-W; 20/2\ 1211\
initial consonant c1wtm L
initial consonant djftlDhs 4/\ ,
final double consonants ,
final consonant dhrranhs 4/\ "-
final consonant digraphs
final consonant c1ullers 4/\
lonl vowel -; :........ '," -~
vowel dilZr.nhs 4/\ ' , , -, ..,....
lonR vowel 4/\
innections 4/\ n 4/\
contractions 4'\ ..
-- 4/\
a]nh.bc1ica1 order 41\
TOTAL TEST SCORE 36'45 ..:;/ 36/45
1-,,2 '1- '13
Suuested
Passins
Seore A 8
8/10
8/10
4/\
4/\ S
1211\
4/\
4/\
4/5
14130
LEVEL 5 UNIT 1 UNIT 2
DATE
Dislrict SUUtsled F,~ SUUl:Slcd.
Use Pusins Passins
Seore A 0 Score A 0
V_........ 12IIS 1211\
lesled vocabulsrv 8110 8/10
,vnonvms 4/\
c1anification 4/\
eo 4/\ 8/10
tause/eHect 4/\ '.-
main idea/details 4/\
drawinR conclusions 4/\
~ 415 ,-
characterization 4/\
ud Wont -w; 16/20 8110
final consonant clusters 4/\
IOOlz'o'owels 4/\
'onlraclions 4/\ I
l:omoound words 4/\
",owel diRranh 4/\
.""lIin. chan... " ...~. . 4/\
TOTAL TEST SCORE 36/45 18/35
.3 -.2.3 -7.3
SUUt:Sled
Passin.
Score A B
1211\
8/10
4/\ S
4/5
4/5
16120
8/10 7
4/\
4/\
31/40 ;) b
-
~
. . - lY - . .
, REAIlING
SILVER BURDETT and GINN
READING PROGRESS CARD
Levels K-14
Name
School
i',' ". h (' I c{gr'
I'll, c/o i"",F.<
Date of Birth 1..: :' 7 / YC
Date Entered ' ~ /" / /yj
The Reading Progress Card provides a cumulative record of a student's reading success. Scores for Placement
Test and Informal Reading Inventory results can be recorded, as well as scores for Unit Skills Tests
(Forms A & B), Unit Process Tests, Mid-Book Tests, and End-of-Book Tests by skill and strand for all
units and levels in World of Reading. It is recommended that the Student Score Sheet accompanying each
test be completed and the results transferred to this card. Suggested passing scores by unit and level are
provided where appropriate. Also, a "District Use" column has been provided to allow you to customize
this card to highlight local or state instructional objectives.
PLACEMENT TEST
DATE
FINAL PLACEMENT
Levels tested
INFORMAL READING INVENTORY
DATE
FINAL PLACEMENT
Levels tested
KINDERGARTEN/READINESS
KINDERGARTEN
READINESS
DATE
OntriC1
U.e
SUale1lcd
Pauin.
$o:Of(
Suuencd
PalSin,
Score
5I::Of(
ScOle
'"," .
22128
14/l7
4/5
40/50
7/9
7/9
7/8
21/26
. ~~ ,; .':: ~-: ~~4;"':t ~...' ~
..-< -:,!.-".,';",=
~.-~. , '.. :,"",- ~':':l-':.~ ':'a::rj\';.~~.:-:....
,'o(
'.'
Copyriahl Silver. Burf;!eu &: Ginn. loc, All nlhls fCiCI"'N.
- ~~----
LEVEL I
I
DATEl
I Dlm,,:1
U..
A
,(, ' ,10:
- 01"'! 1.-1
SUU(1IW
P1Ulnll
S~or(
MIlO
8/10
J/S
J/\
12fl!
J/\
4/\
J/l
V
tested vocabula
eo. .
uence
uti Wonllllo
nnal consonants
short vowels
inflection
"
,
,
, .
/.J
TOTAL TEST SCORE
U/JO
LEVEL 2
DATE
District SUUCiled
Use Pusin.
Score A B
V 8/10
tested voa,bula 8/10
.,.. , 4/1
J/\
12111
4/\
J/l .;
4/1 3
TOTAL TEST SCORE U/JO ,-
,,;,J
LEVEL 3
DATE I I.
District SUUClted
Us. Pauin.
Score A B
12111
tested vocabula 8/10 I
c1usification J/l ."
4/1
main ideal details J/S
...W... 16120
initial consonant c1ullers
final consonant di ra hs 8/10
Ion vowels 4/1
inflections J/l
TOTAL TEST SCORE 31/40 ~
U~II ~KIl.l.~
I
1
I
1t..~I~
u
. -- --- - - ,---- ---.-------.----.--------- -' ,
, LEVEL .- : UNIT I UNIT 2
, DATE I . ". - 'I /~
r DntrtCl SU&&e1lN " Suutl1td I Fo~
t.:\C Pauan, PaUln, ! I
I ~ore A B S~ore I A B
Vonbul... 8,10 16/:0
tested vocabularv 8/10 q 8/10 'I
lntOnVms J/l .
danlfic.lllon 4.! : ..
eo........uIo. J/l 4/1
predict in If outcomes 4/1 /
KQuencc 4/1 ~
U....1OR 4/1
reality/fantasy J/l . .
... woris....1 20121 I2I1l
initial consonant clusters q , ';tt
initial consonant dilffaDhs J/l ;4;
nnal double consonants -) ; ....~.
nnal consonant diuaDhs J/l ~.
flnal consonant digraphs , .,-
flnod consonant clusters 4/1
lonl vowel t) " _:~~:,
vowel diuaDhs J/l
Ion vowel 4/1 ~
inflections 4/1 ;J J/l ~
conlractions 4/1 ;) ....~1i!\o~
'-- 4/1
i"i"nhabetica.l order -, " 4/1 ~-
TOTAL TEST SCORE 36'.s 3.0 36/.s .;7
LEVEL 5 UNIT 1 UNIT 2
DATE ,- :> 7... h, / ;' / '7 </
v
DiS1rict SUUClled Suucsted F~
Use Pauin. Pusin.
Score A B Score A B
V~ 12111 12111
tntrd vocabulary 8/10 - 8/10 ~
lYnonYms 4/1 - "
c1auification J/l ., -
eo. 4/1 8/10
cause/effect 4/S .;- ..
main idea/details 4/1 "
drawinlf conclusions 4/1 ~-
Uta-.. 4/1 ::l-!..,":: .:f'G,..
characterization 4/1 .: . ~.. r.' .
-.
... woris- 16120 8/10 ~
final consonant clusters 4/1 oJ ~ -.
lonR vowels 4/1 ~ .. .- ... ~'"
contractions J/l ~ ...:~.
comnound words 4/1 " -~ 1 ~ .....
.,
vowel diU3nh 4/1 y
snellinlf chanlfes 4/1 ..(
TOTAL TEST SCORE 36/.s - - 11/35 2.?
Lfj
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CUMRERLAND V ALLEY SCHOOL DISTRICT '/;'(,1.'(...'-
6746 Carlisle Pike, Mechanicsburg, P A 17055
3 -9'-1
Kindergarten Progress Report /qq
SocIal Habits
@ @ ~~ h~rI~
I can solve my own I find imponant things I put things away,
problems. 10 do, o Yes o NOl yet
o Yes o Not yet o Yes o Not yet o Yes o NOl yet
o Yes o Not yet il Yes o Not yet
~ ~1l' ~
I participate in group games, I take turns and share, I can dress mysen,
o Yes o Not yet o Yes o Not yet o Zip D BuRon 0 Tia
o Yes o Not yet o Yes o Not yel o Zip o BuRon 0 Tie
. -., 'M 1r.J~J
I work well with others, Ilell others about things I I use good manners,
o Yes o NOl yet brIng or I have done, o Yes o Not yel
o Yes o Not yet o Yes o Not yel o Yes o Not yet
o Yes o Nol yel
--.
(ry I Class R~ltS I
,......-
4.....-
3.--
-
I am responsible for my I finish my lob, I can follow rules,
belongings, o Yes o Not yel o Yes o Not yel
o Yes o Not yet o Yes o NOI yel o Yes o Not yel
o Yes o NOI yel
.. -"
-----.- -----....
~_..t....._
~._.~- _..
e<'=' .
. .-..- .-.. .-
., '
, -
..... ,.1. ".
,
._~~-::;.;
~.. "l ~..
t.-"',\,. "" _ ,.-.', . .
.. .-.),~,.
...~.,-
. ~ :t..",~l. .
'.- .
,_",' .h..
...-..:::....~"":'.."':"...
" Readiness
-=-J-o.h-n-. . 00)(9
I recognize my I understand leltJright I can compare sizes,
name, progression. a Yes a Not yet
a Yes o Not yet a Yes a Not yet o Yes a Not yet
a Yes o No' yet o Yes a Not yet
~ ~iR
.,
II
.
I know my colors, I enjoy books, I can bounce and catch a
a Yes D Not,yet a Yes a Not yet ball,
a Yes a Not yet DYes a Not yet aYes a Not yet
DYes a Not yet
1> 009 ~
~:;.
I can hop on my left fright I recognize likenesses and I walch,
fool. differences, a Y.as a Not yet
a Yes D Not yet a Yes a Not yet a 'ies a Not yet
a Yes a Not yet a Yes a Not yet
~
.....
~ ~j" ~
"-=="
I can cut on a line, I know parts 01 my body, I listen,
a Yes a Not yet a Yes a Not yet a Yes a Not yet
a Yes a Not yet a Yes aNot yet a Yes a Not yet
......------.--. ...-...~.
1
'~ ~
Name
SchOOl
DOB
Teacher
School Year
JanuatyfJune
Name
Skills
tJ.b. 00
!J. 00
I can sort,
D Y\lS o Not yet
Q""'es o Not yet
6.
o
o
'-
. "-
I know beginning consonant
sounds,
o Yes
o Yes
I know the names of
these shapes,
o Yes 0 Not yet
o Yes 0 Not yet
o N.otyet
o j:!otyet
0??o-o
~~
;,V
I
00000
.6 0.600
I can build patterns,
o Yes 0 Not yet
g..Ves 0 Not yet
I know opposites,
o Yes 0 Not yet
Q Yes 0 Not yet
I can count objects,
o YllS 0 Not yet
!YYes 0 Not yet
tl~~
123Lf5
b 7 S q 10
GoD~0
I can sequence,
o '(es 0 Not yet
(}'Yes 0 Not yet
I can build sets,
O. ,0-
o yes- 0 Not yet
o Yes (> Not yet
I can write numerals,
0- ,0- --'
o Yes 0 Not yet
o Yes 0 NO! yet
00 LL
00.'
5Lf1b2
3 Og 8 7
Joh~
--'
I can print my, firsVlast name,
o Yes 0' NOryet
o Yes 0 Not yet
I can match sets,
o Yes 0 No! yet
o Yes (} Not yet
I can recognize numerals,
0- ,0. -.- '
o Yes 0 Not yet
o Yes 0 Not yet
I can recognize all letters except ...
A BC;D-E'f'IGHIJ KL; M'NOPQ R STUVWXYZ
'- \..- - ,/ ..' ~~ '.
at b c,~ elf,g,;h. i:i k (m:'n 0: P qui, t ;~.:. ~;w x y z
. '. .., . . "'- ... .".' .....~. ,
". .- ...
-.' .. .
"
...;..~~..;...; .
-_.......
.....-..
: .:"'.
....,
,.'
"I
-
_.._.._-~- ..
,
Comments
January
June
-.~I..;--~.~"'"
.'-".-..I~~.
Placement for next year
Your child has been assigned to grade --L-Ior the comlng school year.
Teacher lv\. ... . ..l Room
.
....,....-....-.
'--j
,
1
CUMBERLAND V ALLEY SCHOOL DISTRICT vl/!]JuU----
6746 Carlisle Pike, Mechanicsburg, P A 17055 /~
,qqJ-
I
'.
, I
Kindergarten Progress Report
Social Habits
@@
I can solve my own
problems,
o Yes
0' Yes
o Not yet
o Not yet
~
~~~
I participate In group games,
o Yes 0 Not yet
o Yes 0 Not yet
~~
I find important things
to do,
o Yes
o Yes
o Not yet
ONot yet
!f1r
I lake turns and share,
DYes 0 Not yet
o Yes 0 Not yet
! ~J~ I [ ~.J~-91
I~ I I (f' .IJ> I
~r~.!~~i:~
" "-",-",~"
"'....-...........
.:l:~ :"::;:'::;'.".:':
,..... -.....,. -!
,..,....;<..1
, ,
"I
" ,
I work well with others,
o Yes 0 Not yet
o Yes 0 Not yet
~
I am responSible for my
belongings,
o Yes 0 Not yet
o Yes 0 Not yet
I tell others about things I
bring or I have done,
o Yes 0 Not yet
o Yes 0 Not yet
llinlsh my lob,
o Yes 0 Not yet
o Yes 0 Not yet
h~H~
I putlhings away,
o Yes 0 Not yel
o Yes 0 Not yel
~
I can dress myself.
o Zip 0 Bunon 0 Tie
o Zip 0 Bunon I> Tie
I use good manners,
o Yes 0 Not yet
o Yes 0 Not yel
,l'"
"~
...~4;..
,:..:li
CIQs~ Rulu
1......-
2..__
13.- -
"-
:'~~i:
.-!
I can follow rules,
o Yes 0 Not yet
o Yes 0 Not yel
.' *'..J~";",,:"~~.M'-"';7'..- ..:....--..~.:..r. ::,.ri.'. ".-\iJolll..-
~-' '''_'''~' ..--.;.~........,.. .~'-":.t :~.-.;"" ~....'~:,....,.... "c ~ . ;",~::.:. '.:
~.' -~~.':' ~*.-,.'... '. ~ :". . ~::'~~~~~.~'~~:~~~~'~\!:~~.'::.:'~
.- -:-':;.~!~-~;:'" ,::,..
~ ..... .... .-. ~. .
"
'.
t.. 0., .
.. .......:.." II
... .,
~~~;:;:. ~,,~::,-'
..---..-...-
Name
Teacher
Readiness
-=-JO'h-n - - .
I recognize my
name,
Q Yes
o-'Yes
o NOI yel
o NOI yet
I know my colors,
o Yes 0 Not yel
0' Yes 0 Not'yel
-f-
I can hop on my Ie~ /righl
fool. . ,
o Yes 0 Not yel
G Yes 0 Not yel
~
I can cut on a line,
g Yes 0 NOI yel
() Yes 0 Nol yet
School
School Year
I understand left/right
progression,
o Yes 0 Not yel
o Yes 0 Not yel
GJ
I elljOY books,
o Yes 0 Not yet
~ Yes 0 Not yel
y)(jy)
I recognize likenesses and
differences,
o Yes 0 NOI yel
o Yes 0 Not yel
I ~j~
I ""=="
I know parts of my body,
o Yes 0 Not yet
o Yes 0 Not yet
OOB
January/June.
0099
I can compare sizes,
o Yes 0 NOI yel
o Yes 0 NOI yel
~~.'
0'
"
.
I can bounce and calch a
baD,
o Yes
o Yes
o NOI yet
o NOI yel
~~
I walch,
o Yes
,0 Yes
o NOI yel
o NOI yet
::";~
..;
'"..::...~
'""'~
,C . -
-'-:~~:-~\'.;:~.:::~~'~..:i..:";":.~~'-c;.;.::....:.~,,~-r:...;~- ~lUtO........, ". '.'
',. _.,~..:~i~-" .':'':'::'~~~;'~5~:~~~~~~~[:~~~:~ :~~'i!~/P:~~:~~:,~..: "',!".
7 '. ,t..~ ~'7~::~~~~~~.~_..' '::. :.~_
._-..-...~ ..,..._~
i~
llislen,
o Yes
o Yes
o Not yel
o NOI yet
'h
I can recognize all letters except ...
ABC 0 EFG HIJ KLM N9PQ RSTUVWXYZ
a bed e I 9 h i k I m n 0 P q r 5 t u v wx Y z
..---- - .. - . - -
Name
Skllls
6!:::. 00
6 00
I can sort,
o Yes o Nol yel
I) Yes o NOI yel
0?-?oo
I can build panerns,
o Yes 0 Nol yel
o Yes 0 Nol yel
1J~~
I can sequence,
o Yes 0 Nol yel
o Yes 0 Nol yet
\
,
00 Ll
00 1
I can malch sets,
o Yes 0 Not yet
o Yes 0 Nol yet
o
o
6
[ ]
, .
I know 1M names of
these shapes,
o Yes 0 NOI yel
o Yes 0 Nol yel
~ tJ~
1', I \....
I know oppoSites,
o Yes 0 Nol yel
o Yes 0 Nol yel
~
~
I can bUild sets,
0._,0'
o Yes 0 Not yel
o Yes 0 Not yet
\ : ~ gl ; ~
I can recognize numerals,
O. ,0,
o Yes 0 Not yel
o Yes 0 Not yet
. or
I know beginning consonanl
sounds,
o Yes
o Yes
o Not yet
o Not yel
00 000
~ O~OO
I can counl objects,
o Yes 0 NOI yet
o Yes 0 Not yet
-,
\
123Lt5
b 7 ca q \0
I can wnte numerals,
O. ,0,
o Yes 0 Not yet
o Yes 0 Not yet
\ \ Joh~ '
Ii, ---'
I can pnnt my f1rl!tJ1ast name,
o Yes 0 Not yet
o Yes 0 Not yet
, .
\t"'
",',- ,'.':;..' .:,,;,;;:::.,:,"~'~::~?'-~~-;~~':;~
L """____.:,;.!~_.._. ~ . "':'f.. ,.'"l!'.h\--......-r~.. .
. ...... ;:.;:-"~d~,,.:;~~f?~;0..
June
- 'q
,
. -..'.
Comments
. '
Januarv
Placement for next year
Your child has been assigned to grade
Teacher ;\,; t::; :.'1'1 i-:', .-
Room
for the coming school year.
, - I
......0' '.'J
CUMBmUAIlD VALLEY SCHOOL DISTRICT
6746 Carlisle Pike
Mechanicsburg. Pennsylvania 17055
Non-Promotion Certificate
Briefly stated. our promotional policy is that non-promotion of any child is to be con-
sidered a very serious matter and each child's case is to be considered on its cwn merits.
The basis for retention should be the confidence and assurance on the part of the teacher
that tbe child will profit from repeating the grade,
I. Pupil's Name (3Y'1 r e 'P,ri dCje_ Age 5 Grade ~ Date to I" !q3
, l
Latest group IQ (if available) Latest individual IQ (if available)
Latest achievement test results (if available) : Reading Math
Previous grade retained (Please check,) K I 2 3 4 5
II.
~ do Vl'\\ L""" C. ( 1 n () b La- -\-0 L.d.uili.~
\e.ttD61 ~O\\nnlfY\ flnn<:/l(1Cdtt C'.DI..vtd.--: r\l.Jn..ora..I~'; l/flab(, -h.
~ \ - tb :J I 0l'lJ!eS~/I.ClRfl(.A.. -+t, Count olo)ec..t5). ') (I GttTen{::"te,; I oas l
Notification of Princ~pal dls-l-ra ctecJ. J Sh,Of t ~n.'b. ay...... ~ 11 ) c.' I j
~ principal notified of possible retention at mid-year.
v'
Principal notified of retention one month prior to close of school.
Teacher's reason for retention
Notification of Parents
.;
Parents notified at mid-year.
Mode of contact:
.,/ Conference
Telephone
-L Parents agreed.
Parents did not agree.
,/
.
Parents notified of definite retention no later than two weeks prior to close
of school,
/
/
Mode of contact: V Conference _ _ Telephone
/' Parents agreed.
Parents did not agree,
'N.
Sumcary of Conference
Mrs, bv-ar'"\~ i-~
.Mrs,. ~'ri d dO'
.:B Yl cc? ~a.u.4.
oM. te~tl~.
.se.hoo\ CDUf\~\<..l"" 'f'tt-Q.t WI t-h
. )
I\.u.. ("1(1 ci ~; "('\\1'\ W a.s ~C1r1. , +a re...+O , "
O^ o.~h,evef'K.ctd- I Gta.sS(l)Ol'lL J2f!:FortKQflc.e,
Prepare in duplicate: I copy to be placed in the child's cumulative record file
l copy to be given to the building principal
11/78
CUMBERLAND VALLEY SCHOOL DISTRICT
6746 Carlisle pike
Mechanicsburg.?ennsylvania 17055
Mid-Year Difficulty Report
The purpose of this form is to have some information in writing at the
middle of the school year for those students who appear to have some
difficulty with their school work and for whom there is a possibilitiy
of retention in the present grade.
Pupil's Name ~nLe, 53-r'ldc.~e~
Age 6' Grade K Teacher ...S't1 0:1 '0 'j t,:\..j~n!i. II
Parent's Name :D2'n'b-.J :R'tl(\c~e...
Address \')','2.\0 c..\aremul+ ~d.
Date Fe'\:' ;JS I qq3
I
School M',d~ '-1.'5,..1..:"-
Please give a brief description of the child's difficulty. Be specific
as to what area(s).
B'r"Ic.e IS hltVlnqd,II+,t:'dtj \..l..!11ncUI c..rU.{~, .oYI(.<- c;.<l(\ Ick1\~.~,&
O(\12>u::t't1rs B,e,,~~ (), \.le..ca\\S (YJ(.):'+LL-ttIrr.:J bdYLufX.tr~\ IU1p...1~,
\::k CQfI Icll^t..f.iJ Ui\11Y1.Un\Jlrt.,j \, ~ fan ec,ud:.. ma.\c.I~~ a 1- I c.t~?O(\dJlf<'
-\l> ~. e:-.,~ Y\~ ol;}ku.lt'1 f.,ul-t'n srQ./u.h Lr~~c:.i:ll souru/.~ ,l1'Ciph~<l.w...
't:1'f..cs:;,1I<'- \Ct~ ') :i]fl(e MS -fr1lclbU. cl..l.th ~~~ ancl .,.,~ ((Io-ru, ~ lIs,
Date of parent-teacher conference to discuss the possibility of
retention
Summary of this conference:
2'(,,:e.'S mc.\-'tuJ f'r\...O.t \;.;.\-n nu ~ ,..) t....\l.^j 4-0 c:k.
'reJ,~ ,-Doyle C<\- Y\~fU.., C~\th';""'Cjh ~k nc..:ted tnc.t BVI'-L IS
nOT ah..u~.) w,\\,n~ tu \..L>o<~ w.\-n Y1e1", We cliSc..u.:5Sl<.J
N.~e n \-. Qr'\ "2>( I .:...c. 'So m c+ 'iLl r 11 1.U.~+i <),u d.. \).., ~ f\l..u <.J r n '- t +\LJl....
, . r l) - M'j a '(\S~'-"('"
c4-<<.\~?",.,.,"'tG\ 1'"ln+ j:l''t.'''''Y't1>'Y\. I.,l.}c.....tJ b...._ Vf(,uf'lc.:........' .
l L 1 \. J( (' .. I^ N,tc.,,,{:..\ ~
\).Xi) +'na..-r- 0.1 pD::.&lllo IT"'S. rue -r"~~ T'cl<.- 1.',.... (J
Cof\S,~r{rl.
:-')Yu. \ \'--1
~\shoJI
Teacher
Prepare in duplicate: l copy to be placed in the child's cumulative file
1 copy to be given to the building principal
1/92
CUKBERLAND VALLEY SCHOOL DrS'l'IlIcr
6746 Carlisle Pike, Mechanicsburg, PA 17055
Student IJ
_OC;;l. tf'fj-
Name '~r \ rlril.f_
(Last)
Pupil lleRistration and AssiRnment Form
Date Records
Requested
/-:J
ry \( r'
(First)
Birthdate
P lace of Birth
f;", F
~ (Date)
(0'1 r f "Jl\ ,Pt\
- (City) (Stat~7~1
Phone ,-~~ - rrUI .-
----;-:"n.n
.; ~ ,.. 1\
( \,_Tl
(Mid le)
,. _" -:-/-
~. \, -...
..::;
::::)
(Month) (Day) (Year)
Mailing Address \ ~(O c.\. n ('''_rY'N"\-r- '.......Wn rl
Road, S,iet, Development ~;=)~( r; ('3 n r.::'rr'iIJr,-+
Grade 4:V(Vl , Teacher/Team 0(/ tf. 4~u
Curriculum/Level !,ocker IJ
Bus
'iI ~9
,.-
Soc. Sec. I~
J
If/?" .;1...
I'
/
/
School Assigned
/J) ..&11f"'>''-'\A'
Date Assigned
Date Entered
Date Withdrawn
K/')...
Home Room /I
School of Last Attendance
/
/
I
Address of !,ast School
Brothers JAn \v (' no c1 J
'II I () \(h~"', :n,"
\
~~J~~tl:
lJ ,~"')-<1 \
Sisters
Birthdate
Father's Name 1'\ "~~t~ '('" , 'Q~~~
Soc.Sec. H ~'-"lo - ,~(l-l81"1' (1
Mother's Name ~CX-\~("lf IX \-Y,yc...h
(1:aiE) I I (Firs t)
,q\(' - U~_.~\(;-;CJ
Soc.Sec. /I
Biological Parents Are:
Peoplc With Whom Living,
Married
if Not With Parents
Case Worker Assigned
Previous Special Placement ~f any ..L. Speech _ LD _ SED _ Gifted _ PMR
Is Your Child Limited in ~!>/Her Physical Activity? _ Yes .,/ No If "yes," explain:
_ ( s-\LL1-tfr.<., J~'f:') '-}~e(\tj\ IkUuAI n-r ('o...rUSl..Q\-L1rx,p...JoJ
List Any Pertinent Health Information SUch As Operations, Chtonic Illnesses, Visual or
Hearin~ Defects, Allergies, Etc.:
H\ 'e.cD~f"
lImunizatianJStatus: / Completed
Not Completed
Other
The pupil named above is under my custody as parent/guardian. The Cumberland Valley School
District has my permission to request from you, the school the pupil formerly attended, and
that school has my permission to release, all records, including confidential information
and psycho ical examinations. My signature below is to be considered aa the request for
such reco ds be sent to the Cumberland Valley SchooI District.
~~\\~ ct;:J
( ate)
rot Carlisle Hospital
-.::J 246 Parker Street
P,O, Box 310
Carlisle, Pennsylvania 17013-0310
1-800.346-4789. (717) 249-1212
,.. r:
~.
" ,
J ~ f.. . .
-,
SPEECH/LANGUAGE PATHOLOGY DEPARTMENT
P=09~e8. Repo~~.cha~qe S"MM~
-J, ~nl'l \-h.f-r'Y\.",.. , M 0
...]6.1y\ W.:>lhw.1Ylje,..-, kSllLl.. -sui'
~...i <.~ lki~-e DATE. _!!!.I~/q:r-
I-W.- ~rtih 'o-\"~\"l~V," )t Jd~ TREATMENT BEGAN. 'ill r Jell
TO.
FROth
PATIENT.
DIAGNOSIS.
StlKKARy.
PJl'"ir..... ~<; 1't"('(".v1"&... ~"fb..-4t"PY'>-f1l h"..rl' &t-l.ev-"Ii\k"
~, ,4inL~ .It lilltJ\ IlrOY\ l'tfVI" ~I b~ (OIf'rh/ An',,...
~vW\Pll.."k U~. ,1\.riYJ --t't\'", ~me- Bn~ h..~.).wC,...t.('ll"
O'r'l ~c.. ,''h. ''''''fr1l~ b:.r,.,..<;c:,ivl".. 10000Ji~y...,~itl<" 'f}'lf'hf
;w",n r.1l b :r.. (j 1\ 5 ~l \c; I ,.;}vl B.. B'\ ~p rr. v'i.~l.iJ.. '-tv31~11 "''J (p., .~~-rt \
&"1" hl'.h.:w-ioY".:;l\ mz.v-.'~'jfVV1o,t. ~(t"_ -.5' c.UVIN'V't'H'J <..~t.,..
~ ~<;u..,'O.p_ obj~-hfv-t..(') rD~~Y )P~"I/"':'
-t 'I'lo (' L~ I A k", , " 7. lL " I'" n
0.\\ ?o si -n Il ",,> "
~ ~N'11 ~_ k.vf. \
RECOKHENDATIONS.
~ '? 7..
n,,'"
~IU'\'o )
ILl
i / z Ii ...;; t1;>A go... i;; ell" .,ve nJ..<} ~ ,':.,
/ ~
/ ') I b 1-e,Y1 LS ~?o Z i'nc,clcl,
I
{ '. '
>r <;v I'VHI'1CV' -Z n:i 0 m ~ z.-t1 oll\
~""-wrr.~ "'J/"I -(L.f
ST 16111 (10NO)
.~
t
ru - E!JPr[.)lPrrtDN
tZ.lZ,1 rv_c (J.... ~ e.e. ~ ;u:l4, 1 l' r
N1\ME:U ~, vri MR NUMBER: --- ~
~QQE~SS: ,-z.U ~~o.-rl- o.1J.. ' BIRTHDATE: q 12..' In
&\isle. PM nbl~ STATUS: 6fJO
PHONE: ~"3" Iq~1
~~I/iN' ...},~ k.O /iC~~'
PARENTS: ~~ 0- ~. bYl'd.~ REFERRAL SOURC~: CA-ll.L
~~~;: ~/;./4> ' v DATE OF ADMl:SSION: NI PI
~I~~~OSIS: M,~~ac~u;~~ DATE OF ONSET: 51'1'11
REHAB POTENTIAL: ~00l0
LTG (Achievement Date - fJhO/4<n:
I. l~ y-G.. -
"2. ~y. ,
3.
is,
STG (Achievement Date - '11;0/4"""'-\:
l-e:lll-z,l ~rk.kl~ q/41.
2. aoz-l CD~IU~f-lJ- ~/'f.d-'
.,. (';hilA- _l.UiU CDrru..+t:J Y\~'" ~~~~~ kYi~~u1PYV", C'omp.1d:iJ.d.
--b..,~ r, _ QOo a.e.t.vt'"o.~ IV'! LD a..1!. . ,
.0\. 0.1\4. w,~\ alY~ l~~,lcoJo,..c, AJJYi"7 rln.rc.-h1~i. l~L
~c; ~D'7a ~Ul"~." '
cAi or ~~/~~TION' "1.J~ YI~~+ :) l'Ylbl'tfl\S -CJ1.lll
~-ve.s l~w~ &v I hr". 10(')
if,
He~a:
. Mtt- t.D~ c3-+~I.s. -hme...
Recective Lanauaae:
. Df'. TEL-O
c;J
@/~
SPZZCK-LANaU~az P~THO~OaY DEPT,
RE-EVALUAT:ION
ST 1810 (9/91)
vv-e
()P fc;>rUA_
e~ ,Br.ic.~
rr'):.'
!
, /' R.E: -E..\/I\UJA-TIDrJ
~ ~ L.(jnf\V\~~tl.. r ~- ~ \
5, ~'\ild.. witt CO....~L,H L) rwr-(JJI"I',-~t!L ~;'/~~~ -:i~~'l \~-:~L
In ,^"onis c" qll40 c-U(lH"'~~'-=-6 ...J.~2c'~5_':-~'+:'__ ,
11hm1C'lAII(c.., ~ <"'.1<;' hllc~v~', IIJ" r ~r " h.,'~l ~"" i:
~ I 0-..1 . ,-::]-'-' '-4- I I l',:} I ~ !..flLC-l I - .
& ailltl ~i lL ror~t.:ft'7 ~Al!c~-~--.:p h()V\..=> ~Y1~ ~~ --.7;-; -:,-,-
~~ :I2b;:.S:r:~ 1, ~()~~_ ~1:t'~U,-'::l~.
I " .. rl~~, _Hi. ~Wl.'(/", '.fr.U ~YlVI"1PVl-l":>.s I V) --
__~s _ .:...-7., _,.rn"I,!Y2.!.~_' .._____...
&c.ar1iSe~
SPEECH/LANGUAGE PATHOLOGY DEPT.
PATIENT IDENTIFICATION
0(' ICAlI.~..
l/, I ,1'j<' ( l'.......:e:.
PROGRESS NOTES
,~ 0505 111(, ,
@J Carlisle Hospital
246 Parker Street
P.O. Box 310
Carlisle, Pennsylvania 17013.0310
HIO()'346-4769 · (717) 249-1212
SPEECH/LANGUAGE PATHOLOGY DEPARTMENT
FILE COpy
'tar"... ,
J.~V\n ~U1/""0
'>. .lsan W. (~hvVCl~eV"/ NSlac.-fi1lP
, Par insuranc. purpos.s would you pl.a.. &:.vi." th. following .UIIIlIIary
of your pati.nt's progr.... make remarks/r.commendations if you .0
de. ire, .ign and r.turn in the enclo..d .nvelope for continuation
of patient tr.atm.nt. Pl.... make . copy for your r.cord..
q/I8'/tI,'
(, /151q ;yo
FllOK.
NOTE.
~nc~ Bnc1.5e.
~aT:t!'ICATION PERIOD. 5'/17/'10-
MDd.era-k.- Spoech... leW~YdC:lJ rkla3
PATIENT.
TREATMENT BEGA!h
THROUGH .
DIAGNOSIS.
stIMKARX .
-oviu:. .s ~howi its 1>"\ niJ Iich"YI C
~'I 18 n-Lphone~s L s. , 61-\ ). +k i> c IIr~V\-l-lt..:l Z!.::>lC: '-n;
~dllu 151 COI"V"I"'L-tt'] il'\ e-~lI~i-t1l\I'\C; tlr wor?;ls SfonicH"It"""'lsl,:) (7
~10 3Cl.\l"iS'~~DW'(.V\7 l..liV1i~'I~ ~kl .~"l"YI'U'lu.... ;-; C\ :5'l'c.
]rbdvd-io(\ Of /7-1 IY". ~ I V\I-ti... , \,osrtlO(,\ 1"" ~~~&.s_ IS dT,
loOo. ~vV'~4\loWjV\') r.tiV\ic..i~~ rnoc.le l. J?nc.c. 15' v-tC....r.:I,yJ
~(6t) \ .?'\ -f11~ ~l.w-k.v)cr~ If'A1f. I ~ porft.::'7\ ~OlfS Lz.;{ - "pt::f'J'~''''l;:1 ILC
-, 5 i:}-r ,~tY?' ~ cc.. u.... a. ':J .
(~)
ST 1815 (10/901
f
RECOHMEND^TIONS.
'!~r1CbM~~
. ,.... -, ~. I
-
UM G
1~llf'I~ ~r (l~~ Vh6Y\-rh
""t u;!. t; d VI V rc lJ y1.-1 rn . n U. &- ( III '
-.
. '
.~ ".
Sincerely,
Cl..,..-~.Ia- WO&- tCAt~
.,' ~:! . : . ., ..'
". .-..,-.- ':--.. ...,".-
PHYSICIAN: I approve continued treatment.
1~~
., .' .
-ur
,s-- Z't.-'7z..
DATE
,-
REKlUUtS :
ST 181Sb (10/90)
,0' '..
"
( i L ENJEQ ~f)n(0
BIRTHDATE: q/.J./ /'8'7
.
KR NUMBER: ~ 05~..t1'-l8 DATE:
ADMIT DATE: "'IA AC~ ~~;
3/:1./'1>-
. I
- ,
E)ClJres~ive Lanauaqe: ~r7(.~ C\)~o"weC; ~ -e.<hipjT-7WZJo",,,"""}
c:d'~::t~:;;:~:. 1'.eb~ ;?s+ or ~ j: ,; (,.. '''{'I.
Brirl'_ 6'b"t8C",,.,A ,..-:J V'.,.:l ~v 'Y6''"e tf' 4'5 r; rlo fvtvl'rh /('> -;,tcot:' "(
Coqnition/Memorv: Bt~. o,..VY1M'l.s~., Cl9tD -....:JFfnf,.';.~. .
ety1i-fi n"5 ~ i/ll.4>.r pV1l ~I~ I'Y1 ~l VI",,? q.... Vlo1'-WIU1j '.:.J.:. ,II~
Oral Peripheral/Motor Speech Examination: A-tl '!;h-Vl'A'f't: s
:yo- + ,01 on ;h~ I/'./NL-..
V n ~W' l
+- mOYl~15 .
1Y"l.: 4 s~*'r:ss.
-rt1e 44rhc::ul;;:ltio",..5U"l'''r"'''''i~ -A,'\.Sl:SSmer1i- WaS vst:c('-k.
~.v..:dlJ~ Bdu':s ...."vnA e.....V"l:......s ;~ lNorcLs 4- Se~'kJI(r".,
,'111(. f1lu.vi('l7 :50v.,().. ,'3l..'L?.,iitvt1/~ (~..rn:.1"'S W~~ J7,,~t.',
fls~. O-?I,j,l::/, W{i'c,-: LoJ/I~T: J rJ.!V'''',' -N:sL; fl:;~
;:f.,~~~ ~~~~~', :/~> ~t~~;F~F~\~" "
. O\rr/a.~1 '~\-kJ.li.~il':llll~ IS ~I"" fv- C:OYl ~"tOYS,"f1cil
III.
Fine/Gross Motor Skills:
. -Evz.luz-ncJO"\ r";n /'1"T' Cb(lt.lu.d..~~L
Behavior:
. C'oopt'....-z-ti\.'l'"_ .;aA'"~ '~,Io,-h~-e... .
~ID=SSION:
Ylec:ue. SRI> ('OMV'(1lJl"l ; Cc')+lc,"" Ax
o
\ ~f'
t\~ '-fT; '-f-i..",c. Clj\ln ,'/..:
+ ,.,0 h.?t, . pHe~rl1.,~ { .
, .
Of'/C:::A\L~.
eric1&jc I f,r:ic.c-
CH-LANGUAGE PATHOLOGY DEPT.
RJ!l-EVALUATION
ST 1810B (9/91)
",
::? E ~CH/ :'.~~;:~'.' A'~::
?~(" ~:.;;;=,:: ,J:'="'~-
.'.-..:. --... . -, ...." ,
:-;ame: .;3r.(..:. ,dr:c4;-
Grade: K.
Sc:,ool: 771/ ,:iJf....:..:;.~
Date: 9~ /.5', /9'1'1
Teacher: '1nru, e..hi:z.ar
Your child has been receiving Speech/Langua
the area(s) of:
V'" Articulation
v'" Language Skills
I/"" Fluency
Progress: ~ol
.
Comments/Recommendations: ~/Tlu{t?rontn.k htt..vp, }'Y.fJ" rYrte.d...,-" 13r,.~:s
,
I-i ('1Lnt.::jS and... /) bflJ -I." <h, /? f)"'" /Jurdl h tI.(,J AI .A, J?->.A ~ ~ &<1<1
'7J ~, ~ 1')-'
fSt.u.5S;""S c;I./,_ ,('1TYIj-"n'~"A -I-n /h{Ji'A ,1'.J,int'O"""''''''' //.-11;"<1 .hI? j,J'~
11.11 ';'.tI~,tl- 1'l",,'LlJ d~'/ L.Y>'j#l/l/JV;'(f1 l.lJ..il-l. +h~ hUJ.si;
:rn:' , , ~Vl.r. ' ~
f
'n/,.lL, f", ALJj~ rI'IlLtJd+v U).i./.J, ih...~;.)/, ~Od.l~';:,n OJ flu..
!St)tLA'ld.. ~ ~~.afr~. ~/~??~
rc ~ ,An-zh'I"'1.J NY ,ni-o /It.<.. /'tfl'f-qs- ~1/'1-.s5,f~
~l! have comments/questions, please call me at ~q7-';)''',:'''::J~
"JnN. ~/)d.
Speech/Language Sup~ort
SPEECH/LANGUAGE PROGRESS REPORT
Name: tJrl C!.- g,~,d7-
Grade: K.
Teacher: /11rs.t!J-'i2t'cr
School: '-1'11 itld b,:? { ~
Da te:.'11111 'N
Your child has been receiving Speech/Language Support in
the area(s) of:
~rticulation Voice
v'" Language Listening/Audi tory skills
/FluenCy
Progress:
JOIJd-
comments/Recommenda Hons: ~ ~ /J?7~ -I-I'K...- l7?O!if
;01iJ"jU,a_d .t'><./ .hu. d,.,....d-iI'M.iAh.t:'?"l /l/?7.d.... L~.-nf/"~~
~ . ..,h.., ..J.I-u-. ~l/z.L....;L.. 1"1 -I ~ .L,c./ ,....,.,..(f -L~ J'l..i4
(, r (I
UNfJ7 fv ,U-..u...- 44'na:.>/h, ,d-?.,.h'11ULh'L", ~t'JI L~
J1&I..iLTYh. 4JL.io,,7 h{<-. h /rnihLJ-e- rn(..y/??odtd~
v
J- '/ sn~"jL - ~//1' ....
i ii-Jr-" '-II th/ tUU.-7'2j ..j-ll..i..? A1 Iu:... chCrn/.
Mz.:h' IV-.J'; . 'fzJ tl'~/"X <''-.,' -Ihis,
,.a.-
It~ ti.HLL
If you have comments/questions, please call me at ~qq-5~~ .
/,toQ7-;;J3b::L
~ r.:5. v')??,rUI~
Speech/Language Sup~ort
t)i {IOU' tL ..b~ h ~~, yt.LL...&... tZ-v&'4 Z:zA/ .<!._
(h-, lhursdEUJ< t'2l'r/L 1-<11-1, durt"J' ;JP-'~
,Cm) /2/u'.. 'n{',.;.<' ,
~
OI/a/4y ifckd Q)~~
6746 Canu/. PJ.., M.cMnic,bl4rg, PI1, /70"
Ph""" (7/7) tR7-826/
PARENT NOTIFICATION
MULTIDISCIPLINARY EVALUATION/REEVALUATION MEETING
Dear
lJ)
'(.horul1 /:Jr;d:..~.c~
.
Name at Parent (5) .
/,/1.?
;10 y, :.1
Dete
Ra: 8ric.~ 8ric4t---
'.
o Eyaluatlon
~' ReeydUll tlon
Your child has been referred for a fr.4ultldlsclpllnary EvaluatlontR~:~~uati~t educational status. As port of
tne evaluDtion/reevaluation procoss, we are requesting a meeting with you as the peront/guardian/surrogate parent
and/or student. the professionals who have conducted the evaluation, and other knowledgeable persons. The names
at tho meeting participants are listed below. During this meeting, the results of the evaluations will be
reviewed and discussed. Reconnendation will be mode as to whether or not your child is, or continues to be, on
exceptional student and in need at special education programs and services. Recommendations for the student's
educetlonal progra...lng will also ba prasented. Tho results of this eyaluatlon/reeyaluatlon will be Included In
a Multidisciplinary Eyaluetlon/Reeyaluatlon Report which will be drafted during tha meeting.
Your participation in this meeting is important. It ~ill give you the ~~nlty to provide those In attendance
with your o..elnlons and Insights. The meeting has been scheduled for /'i ~ A/ov, 1'1 /9 'f.j>
at ,.:)/Ou . VCXl may decide not to particIpate in the Multidisc p'linary EvaluatiC;;n/Reevaluation
moetlng. If you do not respond to this letter within ten liD) days, the _tlng wUI be held In your ebsence.
Names ot Meeting Participants
Position
c
Within twenty (20) school days following the Multidisciplinary Eyaluatlon/Reeyaluatlon meeting. an Indlylduellzod
Educetlon Program (IEP) planning meeting will be held to reylew and discuss the Multldlsclpllnery
Evaluation/Reevaluation Report. It the IEP planning team decides that your child is, or continues to be,
except iona I and in need of spec ia 1 educat ion programs and serv ices, an IEP ~i 11 be developed/rev ised ta meet your
child's identified educational needs. VQJr participation in this meeting will be requested. Yc:u will receive
notification 01 th.. date and time lor this meeting lollowlng completion 01 the Multidisciplinary
Eyaluatlon/Rooyeluatlon process. You...y eloct to ""IY8 "t!!,!.tI~ period bet_, the "'Itldlsclp~lnery
Ev..luatlon/RIM!Yel....tlon _tlng ..nd the IEI' pl!,nnlng .....tlng and ~uest the"iEP.pi"nnlng meeting be held
Immod lately al.ter "t~_':4'!.! t I~J sc Ipllnary"!,ye.1.~at lon/Roeyaluat Ion meet Ing. This opt Ion cOmb Ine5' 'the two meet Ings
'I-:. ~one. (If.~ ""'!t~_I!D__tlngs. to.l?Dhhe!dtogother. pi........ note. this on the batt.. of this f;'':';.1 '
n.~ will participate In the Multidisciplinary Eyaluetlon/Roeyaluatlon moetlng.
'Additionally, I would like tho IEP Plennlng ...tlng to lo.odl..tely follow the "'Itldlsclpllnery
Ey..luatlonjRoev..luatlon ...tlng.1 I understond that I will not have 0 typewritten copy of the
Multidisciplinary Evaluation/Reevaluation report prior to the IEP Planning MeetIng. 1 understand
that this letter ~ill serve as a notice ot the IEP Planning Meeting.
Evaluation/Reevaluation meeting.
Parent's Signature
Date II -//43
return ..U copies IIlCcapt II!!!!! to: 41/ nt!.- 111~
or telephone dt.JQ-55:?C. to conllnn the eppolntment.
Please cooplete this
Page l of 1
.
CUMBERLAND VALLEY SCHOOL DISTRICT
MULTIDISCIPLINARY EVALUATION REPORT
INDIVIDUALIZED EDUCATION PROGRAM COVER
Brice Bridge
Date Of Birth 87/09/21
File No. 9027
Middlesex
class of
2005
SSN:
179 6B 0559
ASON FOR MDE: INrTlALEVALUATlON
RTICIPANTS:
CIRCLE It p,....nt(P) or conlulled(C)
tNmAL AgrH or Do Not AgrH lor both "'DE .nd IE
ENT IS REQUESTING PRE HEARING IF THEY 00 NOT AGREE)
X REEVALUATION _IEPREVlEWOM..Y
IIlEDATE: '1llfJlQg
MUL TlDISCIPUNARY TEAM
RECOMMENDATION
Ageta Do Not f1qee
IEP DAlE: II 1I'l1'l5'
IEP CONFERENCE
PARTICIPATION
A9ree Do Not Agree
PC
PC
Brice Bridge
PC cL..h
pcf'"i, ,.1'"'\
PC _
PC
~
.
~
PC
PC
~~
~4
~~
~
PC
PC
PC
PC
MMARY OF ELIGIBILITY AND PROGRAMMING:
THE MDE RECOMMENDS THAT THIS PERSON IS X EXCEPTIONAL """7":-:: NOT
ECK ALL THAT APPLY: _ EMRlTMR _ LD ..L SPL
AutismIPDD DeallHl _ Multihandicapped _ OHI _ SED
Blind NI _ Dev Delay _ NI _ PH _ Gifted
MDE PROGRAM RECOMMENDATION: (circle)
, Grol4l(s) I" :l,. I Leve~! Intervention
ES GS LSS@ ,10 ,eYRR PT FT)
S P L Middlesex
EXCEPTIONAL
(bkiJ) DATE OF EXPECTED
Location INmATlON DURATION
fil,dd/~5e1( 1'/'9/f3 "/1'1/'1'1
81 193 61 194
81 t'94 61 1915
EVAWA1IJNS: v None Retest
CONFERENCE SUMMARY:
LOCATION ollEP CONFERENCE:
Date MDTIlEP INVITATION was sent hon)ll:
Date IEPilIIORA was sent home: .../ WA
INFORMATION FOR PARENTS (check):
0Iher
_~ ---':::"':sam
1111 /13
/ )
~ given to Pll/er1lS
rr-e,";Ool.!;/'1
lB..Ef'HClt\E
not needed
Ice Bridge
UP.n..ARY OF FINDINGS:
PRESENT LEVELS OF EDUCATIONAL PERFORMANCE
Igniricant hlatorlcal Inlormatlon and atrengths and needs derived Irom educational assessments. parental input.
edical and other documents,
Individual Psychological examinatIOn: FS Dale:
~~~SE!~~ ~~..E~~ 0~ SFEE:H L~I~Gu~G~ PERFaRM~NCE
l~r~i ~lctor S~~~U5
5truc~urE5,'f~~ctl0~5 ar~ ~deQua~e ~or sceecn purposes.
Soeecn ~5~gL,ag~ ~n~~vsl~
8r1c~ nas rece1~ed tnera~y for one year at M1ddlesex
El~mentary ana for one year at Cartlsle Hosp1tal Emphasis
nas b~en en artlcula~ion, language and fluency.
Artlculat10n skIlls have lmproved. However, errors contInue
to OCCI..r on ..1 ,r ,91 and vocal ic ir/. Spontaneous speech
lntell 191b1l 1ty 1S fa1r even when the topic of conversation
1S noc prevlou~1~ ~:nown.
Language comprenens1onle::pressHJn Sk1lls are also imprOv1ng.
DurIng a classroom coservat1on ~nd spontaneous language
5am~le. ~rlce W~$ ~o)e ~o unoerstand and use a variety 04
3en~ence types, Some errors wer9 noteo wlth s~nta:<.
~I '.~=i""I.:... =~ 1" .:: ~r'e 1:-,':un51stant :;.lid range from 5(J~~ - el:-%
t:'len~. ~:= .:i:?==r-,:c,m te-=,.cr.~r "i\S aiso r,,:it.l.:ec ;::-So""l'~OS 0+
. .~::.:"~ ..=l?-fi ;_>=:-.~'. ?,!,,:.~ 5t:ated t!iat hlS general aC1:1vlty
a,~ ~a &.S~ lnCO~~l5ten1:. The m~JOrlt.i oi ol$~luenCle5
5re C~!-t-~oro ~epetl~lons wnlCM ~c~ur at the lnlt1atlon oi
utt~~;nc~s. ;r~iO~;&tlOns h~~~ als~ oeen ocserved. He 15
aOi2 ~o lm:~~t~ o~tterns of 5io~, easy 5ceeCM ~t the
$arlt.e!"'"t.:e i-e,ei,
EOI_\.=~.tlOnai I.ncl1C3tl.~ns
5peecn/language fluencv dlfflcultles may interfere with
8rlce'~ communlcat1on attempts wlthln the classroom.
CONCLUSIONS AND FECOMMENDATIONS TO IEF' TEAM
Speech/Language Support should contlnue. Speciflc goals and
obJect1ves WIll be determlned bY the IEF' plann1ng team.
CUMBERLAND VALLEY SCHOOL DISTRICT
CVSD-8 SPL
NAME: Brice Brldge
GOAL AREA: Speech/Lan9uage
DATE PREFHRED: ~/~/~
DATE ACHIEVEC':
,
---
ArmU~L GOALS: To Increase t I uenC'i
T,~ IffiPro',e artlcul atlPn
To Increase 1 an9ua;e comprenenslon/e:<press Ion
~SJECTI~E: I D~;E ;NITIATE~: _,_ DATE ACHIEVED: _/___/___
will De aole to es~aDl Isn a tiuent pattern Ot speecn in short sentences
;(" of tne t lme.
OS,JECTlVE:: :,':'TE IIlITl':'TEC,:_
wli 1 Qe iota tu estaellsn a fiuent
C:lliVersatlons ~l).~ 0'; tne time.
('A TE ACH I EVEC' :
, I
pattern Ot sceecn In orlet
O&JECTI'JE: 3
will oe acle
the tl,ne.
DATE INIT1HTE~: _ _
to correctlv proouce .1. In all
DATE ACHIE'JED:_'_'_
OOSltlor~ :. ~~r~s 91)~ 0';
OBJECTIVE: * DATE INITIATED:_,_'_ DATE ACHIEIJE(':_/_I_
will De aDle to comprehend/use sentences With plurals. possessives, and
past-tense 'teros 'f(,:: of the time.
PROCEDURE:; FOR E'JAL.UATION:
_1. SubJect Acnlevement
-!-2. Instructional Assessment
-!-3. Direct Observation
-!-4. TeaCher Judgement
_5. Standardl:ed Testln9
_", 'Jther
E~AL.UATION SCHEDULE: Midpoint and annual reView Ot c~rrent iEP.
SFEC1ALLl DESIGNEC' 1 NSTIl.UCTIorl
Tr.e 5peecn and language cl lnlClan wl~l ~rOV1~e:
~~al' grouo ln5tructl~n
:ueln;;~rCmPtlns
Mum~ oractlce cr09r~m
Con5ultitlon/c~iia.~oratlop
.-" h',
~und~ (-Y~ Q/~ (q;u~
61-46 Carlulc P.J.c, MCCMnICJb..ri, Pa, liO"
PhON (ilil 697-8161
REQUEST FOR PSYCHOLOGICAL TESTING
Student's Name fir, l e Br,' cJ,j P
Counselor 5 ~ra h " Ie. School /YJ, 'rI.J /~.sC'J{
t. 'Bo vJ~ rS, S/I- pa t/,o J ,,'] IS T
Type of Referral:
Initial Handicapped
Initial Gifted
--X- Initial Speechllanguage /0 ~.:J.1-9 d-
Retest
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(The bottom section will be compleled by lhe Pupil Service Office and the lorm relurnad to you)
Psychologist Assigned:
Dr, Martin
---- Ms, Coslett
I.U,
Date Assigned
/O/~7
Date MDE must be completed
11!4fJ
Other comments
c:eUHlbel/a~d (-1I~&?, rQ/dcd Wi4Ak~
614EJ Corlul. P,k., M.,h4nIClburc. Po, /70" Pho"" (717) 697-826/
MULTIDISCIPLINARY COMPREHENSIVE EVALUATiON REPORT
A. Student OemoaraDhlc Inlormatlon
Name Brice Bridl!e
Sex M
Student Social Security .
Birth Dale 9-21-87
School
Grade K-p.m. Teacher Mrs. Gutshall
Middlesex
Ethnic Background:
American Indian or Alaskan
Black, not Hispanic Origin
-1L White. not Hispanic Origin
Aslan/Pacillc Islander
Hispanic
Other
Student Address
1226 Claremont Road
Carlisle, PA 17013
ParenVGuardian
Deborah
Parent Address (II dlllerent)
Home Phone 258-1721
Work Phone 243-3335
B. Relllon lor Relarral
Relerred by S. Gutshall
Position Teacher
Phone
Reason lor Relerral
Concerned about possible speech/language difficulties
which interfere with learning.
CVSD-I
Pege I 01 2
STUDENT NAME
Brice Bridge
C. EDUCATIONAL. SOCIAL AND PHYSICAL HISTORY
Vear
Grade/Assignment
SchooVAoencv
Suooort PrnarRm/ServiceR
1991-92
-
Carlisle Hospital
S/L services
Achievement Tests: N/A
Name 01 Test
~
Scores
Intelligence Tests:
N/A
Name 01 Test
~
Scores
Individual
v,
P.
FS.
Group
FS,
Instructional Levels: Reading
N/A
Math
Current communication skills Brice is difficult to understand. at times,
Expressive language, articulation, and fluency errors are noted.
Specilic behaviors or difficulties in the classroom that interlere with learning
Medical History: (include illnesses/surgeries) Adnoidectomv: and tubes ( 3 different
times). Had received S/L therapy at Carlisle Hospital
Other significant medical information:
CVSD- ,
Page 2 of 2
'_'.' H
'~
0r~, (2/~ ((Z)~
6746 amillc Pik~, M~d\4rUabwr.. Pa. /70"
MULTIDISCIPLINARY EVALUATION CONSENT NOTICE
Ph"", (7/7) 697-8261
Date of Request:
lo-/t,-9~
NAME: Brie e.. Br .'dS ~
DOB Q-')'I-f?7
.,v
resent Class Location: .;rJ:dJlt!r;"",
Social Security ,
Grade:LTeacher: /1..<; r:..u -1<:: J..n /I - Pm
The
To help determine needs in educational programming, your consent is required to
valuate the above-named student. The HD e~aluation team will include yourself, the
tudent's current teacher, a certified school psychologist, and other appropriate school
ersonnel familiar with the student.
Proposed areas for evaluation are indicated below. Refer to the back of this page
further explanations of each area. If additional assessments are recommended during
he MD evaluation process, you will be contacted to discuss them. When necessary, you
II be asked to sign an additional consent form.
l. Intellectual/Academic Ability
2. Educational Achievement
3. Social Adjustment/Personality
4. Communication S eech and Language)
5. Perceptual/Motor Skil s
6. Ecological/Life Skills
7. Vision and/or Hearing
8. Neurodevelopment
9. Work/Vocational
La. Other (Specific)
You have the right to inspect and revic~ all relevant school records concerning the
tudent. You have the right to meet with a member of the multidisciplin~ry evaluation
eam to discuss the referral and proposed evaluation procedures. You have the right to
ive or withhold consent for the evaluation. Ynu may object to the evaluation and request
due process hearing.
The evaluation will be completed within 45 school days after the school receives
~ns~~t . I
~ give my consent for the MD evaluation as noted above
(Initial)
I do ~ give 'my consent for the ~ID evaluation as noted above
(Initial)
Code
c
Work Phone
Phone ,
ttachment: Notice of Procedural Safeguards
Page l of l
(See Back)
~ande~ Cf/~ Q/~ q)~~
6146 Car/ule Pike, MechanlC,burg. Pa. /70"
Phoru (7/7) 697-826/
PARENT/GUARDIAN REPORT
Student Rf"'c P.. Rr, 1.3(':> DOB '1-.) 1- f! 7
As part of the Multidisciplinary Evaluation/Reevaluation process. we ask that you provide ua
with information and opinions that will be helpful in identifying your child's educational needs
and preparing recommendations to meet these needs,
Please refurn this form to L, B" l.u ,. r oS
by ItJ-~/-9;;J. Thank you.
.
A. Instructional/Academics:
Strengths/Concerns' (\ ^ _
~U-- t2J\-J'cf ~~Lfl8"
B. Communication Skills: (spoken and written language)
Strengths/Concerns J
~U.O ~\~~\'\ud ~t 1'~Lj{D, 9b
{}(10n(l h C1N. a.t (b.\ C I ,~ CU~ ~j <:.. ,Cf.tL-ttt'\..D ~ ~
I~ -' ,~ "IV'-"-
C. Behavioral: l..A..... *- ~
~nglhs/Concerns, '
~~ac,~~~[;'~'t)~~l.P.)~
..:::fv~ ,rO:L ~~' LJ,.JJ
D. Social: (How does your child get along with friends and ad~tS) lJ (f .
Strengths/Concerns
~t\o ~\.a ~ ~i..Un~-\CLu llr6 ~.
E. Please provide any other information thaI you feel may be important in identifying your
child's educational needs and planning to meet these needs (i.e" medical, medications,
recent change in the family, etc,)
I
Date
CVSD-3
Page 1 of 1
.~
c~~ rQ/ckd Q)M~
6746 Carlisle P&ke. MecMnicJbur,. Pa, /70"
PhON! (7/7) 697-826/
PARENT NOTIPIGATION
MULTIDISCIPLINARY EVALUATION/REEVALUATION MEETING
Dear [kbO'fCL J, kl
Name of Parent(s)
Brlclj e
II -jJ.;-9;;L
Dete
Re: Rrl'(' e. Sr.' A j e.
~ Evaluation
o Reevaluation
Your child has boon relerred lor e Multidisciplinary Evaluation/Reevaluation 01 aducatlonal status. As part 01
the evaluation/reevaluation process. we are requesting a meeting with you as the parent/guardian/surrogate parent
and/or student. the professionals who have conducted the evaluation. and other knowledgeable persons. The names
of the meeting particIpants are listed below. During this meeting. the results of the evaluations wIll be
reviewed and discussed. Recamendation will be made liS to whether or not yan child 15. or continues to be, an
exceptional student and in need of special education programs and services. Recommendations tor the student's
educational programming will also be presented. The rasults at this evaluation/reevaluation will be Included In
a MultidiSCiplinary Evoluatlon/Reevaluatlon Report whiCh will be dralted during the meeting.
Your participation In this meeting Is Important. It will give you the opportunity to provide those In attendance
with your ::1 In Ions and Insights. The meeting has been scheduled lor jj-::L,":/- 9..;L
at jV};rf J" r;:p X . You may decide not to participate In the Multidisciplinary Evaluation/Reevaluation
meet Ing. It you do not respond to this letter within ten 1101 days, the _tlng wUl be held In your a-.ce.
I~l~~:"'~'"
.
Position
Names of Meeting Participants
To (;;..."'~. '1-",-
, ,of
Position
C-AU" re /0 r-
Within twanty (20) school doys lollowlng the Multidisciplinary Evaluation/Reevaluation meeting. an Individualized
Education Program (IEP) planning meeting will be held to review .nd discuss the Multidisciplinary
Evoluation/Reevoluetion Report. It the IEP planning team decides that your child is, or contInues to be.
exceptional and in need of special education programs and services, an IEP will be developed/revised tameet your
child's identified educational needs. Your participation In this meeting will be requested. You will receive
notification of the date and time for this meeting following completion of the MultidiSCiplinary
Evaluation/Reevaluation process. You..y elect to welve the t!ole period bet-.. the "-oltldisc1pllnary
EvaluetlonfReevaluetion _tlng and the IEP planning _ting and request the IEP planning meeting be held
immediately atter the Multidisciplinary Evaluation/Reevaluation meeting. This option combines the two meetings
Into one. (It you went the _tlngs to be held together, pl....se note this on the bottCII ot this to....1
I will participate in the MultidiSCiplinary Evaluation/Reevaluation meeting.
~ 'Additionally. I would like tho IEP Planning oeetlng to l.-odlately tollow the Multidisciplinary
EvaluatlonfReevaluation oeeting.) I understand thot I will not have a typewritten copy 01 the
Multidisciplinary Evaluatlon/Reev.luatlon report prior to the IEP PI.nnlng Meeting. I understand
that this letter will serve as a notice of the IEP Planning Meeting.
I will not partlclp.te In
the Multidisci~lpnry Evaluation/Reevaluation meeting.
t-'hot'l.Jl..
Date //-1R'-9.:J.
Parent's Signature
PI....se complete this lorm and retum all copies IIXcept II!!!!! to:
or telephone
to conllrm the appolnt.ant.
CVSD-5
Page 1 of 1
III - Summar of Recommendations to the Ind1vidual1zed Educat10n Plannin
MeetinR Participants
Brice BridQP
has demonstrated the following needs and strengths.
Needs:
To develop greater self-confidence
Therapy for expressive language skills
Therapy for Language comprehension
Therapy for fluency
StrenRths:
Seems eager to learn
Tries hard to please
Recommendations:
~ The results of the Multidisciplinary Evaluation indicate that he/she
meets the diagnostic criteria to be identified as a child/student with
and is in need of special education
programs and services.
____ The results of the Multid1sciplinary Reevaluation indicate that he/she
continues to be except10nal and is in need of special education
programs and serv1ces.
The results of the Mult1d1sc1plinary Evaluation/Reevaluation indicate that
he/she does not meet the d1agnostic criteria to be identified as exceptional.
Louise E. Bowers. M.S. CCC-SLP
Evaluation Chairperson
Date
11/14/92
CVSD-IA
Page 2 of 3
?5<<Hlb~ I-----I/a&;y
ifekd (q;/4~~
6746 Qlflule Pake. MtCM'lIcsb..rl, P4. liO"
Phorw (711) tn7.(jZ61
NOTICE OP RECOKKENDED ASSIGNMENT
BriCel ~".'o.<I~
O.,e
~j 1'/:,mL.:.'..-r
'l. I 'Jll"
Ms. Brl.dce
the Indlvldu.llled Educ.tlon Progr.e (IEP) PI.nnlng Meeting. recommend.tlon. were eode for .n In.tructlon.1
r... ..nd pl..c....nt ."Ign...nt for your child. Th.. I.E.P. Te.... reco....nd. that your child. pr..ently In
IUnder r n be placed/~JK)t)..,.,f"r In 5r~('ch Il."nnuaae SUDoort
s ....Ignnent w.. recommanded .fter . r.vlew of the .tt.ched Option. Fore to ...I.t In Identifying the progr.. .nd
vices that wIll meet your child's needs. As a parent. you hove certoln rights which or. de.crlbed 1n the ettlched
Ie. at Procedural Sat uards. Please car.fully read the intormatlon In this docu..nt. 1t you hove concern. or
further explanation, pleos. contact Cumberland Volley's Supervisor of Special Education or DIrector of Pupil
vice. ..t 697-8261.
X Your child .hould begin to rllCOll_ .pecllll educ:otion progr_lng .. Inchlded In the IEP (IEP aU.chad).
The .chool dl.trlct will not proceed without your .pprov.1 of thl. recomoend..tlon.
Your child'. .pecl..1 educ..tlon pl..ce..nt. progr. _lor .....1.,.. .hould be c~ .. noted In the
..tt.ched IEP (IEP ..tt.ched). The .chool district will proceed with thl. ch..nge within ten (10) .chool
days of your receipt at this notice unless you do not approve this recommendation.
All current specl..1 educ..tlon progr_..nd services should be dlaCXll\tinued. The school dl.trlCt will
proceed with this ch..nge unle.s you do not approve this reco.....nd.tlon within ten (101 school dlY' of
receiving this notice.
"
, .
.
All .peclol education service. should be dl.contlnued .t the end of 'he current .chool yeer. Yaur c:lIIId ,)
Is 1I111duetlng trom high school with a dlplom...
Your child should continue In hiS/her pre.ent ....ign...nt. Your child I. non-exceptlonal ..nd not In need
ot special education, programs. and/or services.
"
~ 'J.~..,
School Ol.trlct
"
C/1, ,1...,. ..'
Superintendent
/ ,.'
the option. below. sign this for.. and relurn .11 cople. (..cept gold).
1 approve the recommendation.
1 do not opprow this rscQftlnendatlon.
t'<.
S Ig"" tu re
reason tor disapproval Is:
,-
you do not ..pprove the recommond..tlons of the Indlvldu.llled Edueatlon Progr.~ PI..nnlng T.... you .ey reque.t o~e
the following:
to request: _ prehearlng conf.rence
med la tlon
_ due procell heerln;
Pege 1 ot 1
CUMBERLAND VALLEY SCHOOL DISTRICT
MULTIDISCIPLINARY EVALUATION REPORT
INDIVIDUALIZED EDUCATION PROGRAM COVER
e:Br,(c- B"da.p Date Of Birth y-:JI-<i-7
....J
ool:/1,cld/C's,,~..- class of .Joe,
ASON FOR MDE: ~NITIAL EVALUATION _REEVALUATION
RTlCIPANTS: -
CIRCLE " pr..ent(P) or conlulled(C)
INITIAL Agree or Do Not Agree lor both MDE end IE
ARENT 15 REQUESTING PRE HEARING IF ll-lEY 00 NOT AGREE)
FileNo,
..:;4- SSN: lIS ' l..!l'~ -~)9
I
I
I
I
'-...-
IEP REVIEW ONLY
MDE DATE: 1100/9.')....
MUL TIDISCIPUNARV TEAM
RECOt.9.lEMlA TION
Agree 00 Not Agree
IEP DATE:t l::Jol q~
IEP CONFE ENCE
PAR11CIPATlON
Agree Do Not ~
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/IS' - L-P@i2i1
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pervisor of Special Education. Ronald E, Eckman
o
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..---
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PC
PC
PC PC
MMARY OF ELIGIBILITY AND PROGRAMMING:
THE MDE RECOMMENDS THAT THIS PERSON IS X. EXCEPTIONAL _ NQT EXCEPTIONAL
ECK ALL THAT APPLY: EMRlTMR LD A SPL
Autism/POD _ DeallHl = Multihandicapped = OHI _ SED
Blind NI _ Dev Delay NI PH Gilled
MDE PROGRAM RECOM~N: (circle) (bldg)
ram(s) (LS ES GS LS~ Amount 01 Time Location
@RR PT FT ,/1.dd/f!st'r
DATE OF EXPECTED
INITIATION DURATION
II 1.](19).- // I.:JO/ <7.'\
1 1 1 1
RECOMMENDED EVALUATIONS: _ None _ Retest _ Other
P CONFERENCE SUMMARY:
LOCATION ollEP CONFERENCE:
Date MDT/IEP INVITATION was sent home:
Date IEPINORA was sent home: N/A
INFORMATION FOR PARENTS (check):
HOME X SCHOOL
/1 I/t. 19:>-
/ /
.--given to parents
TELEPHONE
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Planned Course References for all curr~cular areas are aval1dO'e for reVlew upon request.
Evaluation Procedu~
l, Subject Achievement Test~ng
~ 2, Instructional Assessment
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Sla~dardlzed Testlng
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-
---------------------. ~ --.
['I., l "! '.' '.~ .. : ~ ,''':' 1
------------------------------------
llIDDLE:;EX l'IH' r'JLrC:E
CRIIIE REPOR'r
111'0 Inc # 0768-93
CO Ino: #
--------------------------...---------------------------------------------------
Offense: UIIAUTHORIZEO U:JE vr."
s",; ~ J')~e ^
Status: 0
---------------------------. ---------------------------------------------------
Ucr Code: 07^
CO/TIll' ,:,,'10;0: ::!.' 20r,
"remise R
--------------------------~_.._-------------------------------------------------
Of.ficer' 4
Location
Date Occurr~d: 09,:0/')J
Time:
0', ':: IIL'II-
-------------------------- ----------------------------------------------------
1:!26 CL^REtlOIIT Ilf)^U
-------------------------------------------------------------------------------
Discovered
By:
Last BRIDGE Fir~t Dr.anJ\
^ddress L;:;:o; I:LAREIIOUT ROJ\D
Stat'! FA ;;11' 11')1J Fhone
lIiddle 1'1
Cit., C^RLI:;LE
17171 :58-08~0
----------------------------..--------------------------------------------------
Discover Oat'! : 0?/;:0/9J
Notified Date : 0~/22/~3
Tim'! 1<;uO
Time 1?01J
Valu!! S
VICTI/l:
- - - - - - - - - - - - - - - - - - - - - - - - _. ... - ..... ~ - - - .- ... . - - - - - - - - _. . .... - - - - - - - - - - - - - - - - - - - - - - - - - - - - --
5000
Last BRIDGE
Address 11 ;:0;, ':LARElIfJII'L'
State FA ZiD 17013
Flrst DEBR,'
ROMl
Ph':!ne 17171
lIidcJlp. W
City CARLISLE
258-0890
SUSPECT:
--------------------------- .....-------------------------------------------------
-Ra~~ W ~I" r [)Oll ~~:~~/'~~
Emplover Or.. I:F:rIT:;CIILEn
^7'! 21 Z:;/I, 1~6-48-267')
~ork Phone (717) 243-3335
-------------------------------------------------------------------------------
'.
Last STACKFrE:LD
Address 1;: ~" ':I.^nr::/l"lll'
State P^ Zi~ L7013
Fi r!!t IIILTOII
nOM)
Fhone 17171
/lldcJle
Citv CAnLISLE
258-0890
"Race !!
Employ'!r
Hl'iaht
!j~:' II l10n 0:.. :':~.'!.i3
"ae
l'lork
E',-'!s
40 SSII# 201-50-3758
Phone ( )
Comple:~ion
1'/I>j'Jht lIall.:
'.'11 ?-;:;:-'~' J\'J' 1','1,",1 IIn".. Till:; OFFICER RECEIVED ^ C^LL
tROll COUIIT... ':!Jtf'rl~"r, TO m:E'r UE8R/\ DR rD';;;: [:J REFERE/lCE TO HER
VEHICLE, UrOtf M:J: IVM. Otf 'I'IIF: :it:r.m:. SIlE ^OVISED liE TIl^T HER
BOYFRIEND. IIIt.TUII ::;TIV:KFIE:r.D. H^" IIF.:R VEHICLE AND SHE IMNTS
IT U^CIC lIE: LS "lll/nr.IITLY 111 TRl:""'Jtf HJ AT IlIS BROTIlr.RS
RESIDEIII:E. II [LT')'I ,,/\~: UEEII r. I 1/ lIfG 1'/['1'11 IIER MID HAS BEEN
UZTIII; TIIG VE:IIL':I,I::; 'I H^T :iIlG t'l'/lI~:, SIIE RE:TlInNED HOllr. ,HIJ!I
WORK 011 /lUIIO^', 'I ::' ','.1 MI[) UISCOVEnCD TII^T IIcn o lIE; VEIIICLE
UIIS llISSllll;. '1'1 If; "f:IIICL/; I:Is:,all\; r:; ^ 1'~er, III:JSMI rULS^R
IHTH PA REG, un.I) I~. l'IIE VEal [eLF.: rn BL^CI~ /\ND S rLVER IN
CL'LOR ^IIU IS II 1'\')'-' (IulIH. TIlE vr:II11:I,F; IS OIH/F;U BY DEBRA.
SHE "^:i HP.EII 'rRnNI; TO /;ET /lILTON TO /lOVE OUT FOR THE
I,AST TWO ~IF:F;I::;. :;IIF.: "^O I\SI:F:U II III FUR HER tlOUSF; KEYS MID
THE KEYS TO B(lTII m:R VEIIICI,ES. HE IIAD llo'r RETURNED TilE KEYS
YET. SHE l.:^LI,EU II!S IJRoTm:ns 1I0U:;E III NEI" JERSEY MID liE
ANSWERED TilE PHOIIE AIIU THEN /lUNG UP ON HER.
SHE WIIS ^UVISED TO COIITI\~T IlrLTUII AHU crVF; HIM II courLE
OF OI\YS TO !lETUP,1I ,.IIE C^R, 1 F TilE C^R IS IIOT RETURNED.
C:If^HI1E:J FOR UIIM,,.IInRI::r.D U:,E I'/I!.!. BE: FlLE;U J\(;AIIIST lIJ1t MID
TlfE CI\R WILL BE ElIl'EREIl [1I'l'0 /1':1':.
I/ILT')II IS r:lIl,rF:tI'rr:,' :11'/lY 1111; III I'll HI:; RI!(ll'IIER T II IIEI"
JE:R:iE'{. TIIF; ^()IIPF::'S A1lJ) PII<)p,JF; 1IIIlIBF:P. IS : L8 II. DEAp,J STR!':;:T
-,wr. ~"L
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S~
e: ~z
SEI-TRP-POtICE----Date--0J71779~---------------------MPD-lnc-i-0240=~4--
REPORT \ CO Inc .
-----~-----------------------------------------------------------~-----------
ttense: SIMPLE ASSAULT
Sec' 2701
Status: CA
----------------------------------------------------------------------------
r Code: 040
Co/Twp Code: 21/206
PrelDise R
Otticer' 5
-----------------------------------------------------------------------------
te Occurred: 03/14/94
Day: MON-
TilDe: 142121 -
----------------------------------------------------------------------------
1226 CLAREMONT RD
----------------------------------------------------------------------------
Last BRIDGE First
Address 1226 CLAREMONT RD
State PA Zip 172113
DEBORAH Middle
City CARLISLE
Phone (717) 258-1789
----------------------------------------------------------------------------
iscover Date : 03/14/94
titied Date : 03/14/94
TilDe 14021
Tillie 1400
Value S
o
----------------------------------------------------------------------------
Last BRIDG~~' First DEBORAH Middle
Address 1~6 CLAREMONT RD City CARLISLE
State PA Zip 17013 Phone (717) 258-1789
"Race-W Sex F DOB 05/25/66 Age 27 SSN' 196-48-2679
ElDployer UNEMPLOYEED Work Phone ( ) -
--------------~------------------------------------------------------------
RREST: Las,{-STACKFIELD First MILTON Middle L
Address 126 W NORTH ST City CARLISLE
S~ate PA Zip 17013 Phone (7171 258-0890
\
.R~ce B Sex M DOB 12/26/57
Elllployer UNEMPLOYEED
Height 71- Weight 240 Hair BLK
Age 36 SSN' 201-50-375B
Work Phone ( )
Eyes BRN COlllplexion MEDIUM
----------------------------------------------------------------------------
ON 3-14-94 I RECEIVED A CALL FROM COUNTY CONTROL OF A
POSSIBLE ACTIVE DOMESTICT AT 1226 CLAREHONT RD. THEY STATED
A FEMALE CALLER CALLED IN AND SAID THAT SHE NEEDED THE
POLICE THERE NOW AND THEN THE PHONE WAS CUT OFF. THEY
ATTEHPTED TO CALL BACK BUT NO ONE WOULD ANSWER. I ARRIVED ON
THE SCENE WITH OFFICER WINTERS. WE CHECKED THE RESIDENCE AND
NO ONE WOULD ANSWER. THE FRONT DOOR WAS UNLOCKED AND WE
ENTERED AND CHECKED THE HOUSE AND FOUND NO ONE.
ABOUT 15 MINUTES LATER COUNTY RECEIVED A CALL FROM THE
FEMALE WHO STATED THAT SHE WAS DEBORAH BRIDGE. SHE SAID THAT
SHE WAS INVOLVED IN A DOMESTIC AT 1226 CLAREMONT no AND THAT
HER BOYFRIEND (MILTON STACKFIELDI BEAT HER UP AGAIN AND THEN
TOOK HER INTO CARLISLE AND DROPPED HER OFF. I WENT AND
PICKED UP DEBORAH AND TRANSPORTED HER BACK TO THE HIDDLESEX
TWP POLICE STATION. SHE TOLD ME THAT HILTON GRABED HER ARM
AND TRISTED IT AND SLAPPED HER IN THE FACE CAUSING PAIN.
AFTER SHE CALLED THE POLICE HE TOOK HER OUT TO THEIR VAN
TO TAKE HER INTO CARLISLE. WHILE HE HAD HER AT THE VAN HE
SLAHMED THE VAN DOOR ON HER LEG CAUSING MARKS. SHE GAVE HE
A WRITTEN STATEMENT. BASED ON THE ABOVE CHARGES WERE FILED
AT DISTRICT JUSTICE DAYS OFFICE.
--------~---_._--------------------------------------------------------------
DDLESEX TWP POLICE
lME REPORT
Dat.e 01/15(94
MPD Icc # 0032-94
CO Icc #
----------------------------------------------------------------------------.
!tense: ASSAULT
Sec # 2701
Status: CA
----------------------------------------------------------------------------.
-----------------------------------------------------------------------------
Co/Twp Code: 21/206
Premise R
Officer# 2
cr Code: 04D
at.e Occurred: 01/14/94
Day: FRI-
Time: 2200 -
-----------------------------------------------------------------------------
1226 CLAREMONT RD
-----------------------------------------------------------------------------
Last BRIDGE First
Address 1226 CLAREMONT RD
Stat.e PA Zip 17013
DEBORAH Middle W
Cit.y CARLISLE
Phone (717) 258-0890
-----------------------------------------------------------------------------
iscover Date : 01/14/94 Time 2200 Value $ 0
ot.itied Dat.e : 01/14/94 Time 2220
----------------------~------------------------------------------------------
Last. BRIDG~~ First DEBORAH
Address _ 122~ CLAREMONT RD
St.a&e PA Zip 17013 Phone
Middle W
City CARLISLE
(717) 258-0890
.Race W Sex F DOB OS/25/66 Age 27 SSN# 196-48-2679
Employer UNEMPLOYED Work Phone ( )
.I~~;~----f~i~:~i~~~~~~~~~~:~-~i;;~-~i~;~;---~~:~~~~:t:------------
I St.at.e PA Zip 17013 Phone (717) 258-0890 .
I
.Race B Sex M DOB 12/26/57
Employer UNEMPLOYED
Height 71" Weight. 240 Hair BLK
Age 36 SSN# 201-50-3758
Work Phone ( )
Eyes BRN Complexion MEDIUM
-----------------------------------------------------------------------------
ON FRIDAY JANUARY 14, 1994 AT APPROXIMATELY 2220 HRS., THIS
OFFICER WAS NOTIFIED BY THE CARLISLE HOSPITAL EMERGENCY ROOM
OF A PERSON THERE HAD BEEN ASSAULTED. THE ASSAULT WAS THE
RESULT OF A DOMESTIC BETWEEN THE VICTIM AND THE DEFENDANT.
WHEN THIS OFFICER ARRIVED AT THE HOSPITAL EMERGENCY ROOM I
OBSERVED THE VICTIM SITTING ON A HOSPITAL GURNEY. SHE WAS
WEARING A SWEATSHIRT AND SWEAT PANTS. THE SWEATSHIRT HAD
BLOOD ON THE FRONT AND SHOULDER. ON THE FRONT OF THE SHIRT
WAS A LARGE SPOT OF BLOOD. THE BLOOD WAS ON THE LEFT SIDE
AND CAME FROM A CUT ON THE SIDE OF THE VICTIM'S FACE. THE
CUT WAS LOCATED ALONG THE LEFT EYE AT THE CORNER OF THE EYE.
THE VICTIM REPORTED SHE AND THE DEFENDANT HAD AN ARGUMENT
BECAUSE SHE WANTED TO GO OUT WITH SOME OF HER GIRLFRIENDS.
THE DEFENDANT DID NOT WANT HER TO GO AND BEGAN TO ASSAULT
HER. THE VICTIM REPORTED THE DEFENDANT GRABBED HER BY THB
THROAT, PICKED HER UP AND PUSHED HER INTO THE WALL. BEFORE
SHE WAS PICKED UP, THE VICTIM WAS SLAPPED A NUMBER OF TIMES
BY THE DEFENDANT. AFTER HE PUT HER BACK DOWN, THE DEFENDANT
PUNCHED THE VICTIM ON THE FACE AND HEAD. IT WAS WHEN SHE
WAS BEING PUNCHED THAT THE VICTIM'S HEAD WAS CUT. WHEN THE
DEFENDANT SAW THE VICTIM'S HEAD WAS BLEEDING HE TOOK HER TO
.~'. ..........". "
.'
,.
To THE HOSPITAL. WHEN THB VICTIM TOLD THE DBFBNDANT SHE WAS
GOING TO HAVE HIM ARRESTED HE DROPPED HER OFF AND LEn. THB
VICTIM REPORTED SHB HAD BEEN ASSAOLnm SIX TIMBS BEPORB BY'
":"
THE DEFENDANT. THE VICTIM SIGNED A VICTIM'S RIGHTS FORM AND
WAS GIVEN A COpy OF THE VICTIM'S RIGHTS FORM. SHE REMAINED
AT THE CARLISLE HOSPITAL FOR TREATMENT.
---~~;;;--~------i-::l~nn---:----- -
-----------~~--~- - - -
-----------------------------
Supv Iat:
.... ......... -"'....... ....... .................. .... ....... ,.....
---.
,- -
-
-
-------------------------------------------------------------------------------
MIDDLESEX TWP POLICE
CRIMB REPORT
Date 04/21/94
MPD Inc # 0350-94
CO Inc #
-----------------------------------.-------------------------------------------
Of tense: PFA VIOLATION
Sec #
Status:
-------------------------------------------------------------------------------
Ucr Code:
Co/Twp Code: 21/206
Premise R Officer# 4
-------------------------------------------------------------------------------
Date Occurred: 04/20/9~
Day: WED-
Time:
---------------------------~---------------------------------------------------
Location 1226 CLAREMONT RD
-------------------------------------------------------------------------------
Discovered Last BRIDGE First DEBORAH
By: Address 1226 CLAREMONT RD
State PA Zip 17013
Middle W
City CARLISLE
Phone (717) 258-1789
-------------------------------------------------------------------------------
Discover Date : 04/20/94
Notitied Date : 04/2Q/~4
Time
Time 1207
Value $
o
-----------------------.-------------------------------------------------------
VICTIM:
Last BRIDGE Pirst DEBORAH
Address 1226 CLAREMONT RD
State PA Zip 17013 Phone
Middle W
City CARLISLE
(717) 258-1789
*Race W Sex F DOB OS/25/66
Employer UNEMPLOYED
Age 27 SSN# 196-48-2679
Work Phone ( )
----------------------------------------------------------------------~--------
ARREST: Last STACKPIELD First MILTON Middle L
Address 0 City
State Zip Phone (
*Race B Sex M DOB 12/26/57 Age 36 SSN# 201-50-3758
Employer Work Phone ( )
Height 511 Weight 240 Hair BLK Eyes BRN Complexion MEDIUM
-------------------------------------------------------------------------------
ON 4-20-94 AT 1207 HRS., THIS DEPARn-tENT RECEIVED A
CALL FROM DEBORAH BRIDGE. SHE REPORTED THAT EARLIER THAT ,
MORtlING, SHE WAS ASSAULTED BY MILTON STACKFIELD. SHE ALSt,
REPORTED THAT SHE DID HAVE A PFA AGAINST MR. STACKFIELD.
SHE STATED THAT STACKFIELD HAS SPENT THE NIGHT AT HER
RESIDENCE AND 'THAT WHEN THEY WOKE UP, THEY HAD AN ARGUEMENT
AND STACKFIELD SLAPPED HER ACROSS THE FACE. WHEN HE LEFT
SHE THEN CALLED US.
ON 4-21-94 AT 2035 HRS., I RECIEVED ANOTHER CALL FROM
MS. BRIDGE. SHE REPORTED THAT BETWEEN 2400 HRS AND 0500 HRS
ON 4-21-94, STACKFIELD CALLED HER 6 OR 7 TIMES. HE TOLD HER
TO COME GET HIM OR HE WOULD KILL HER WHEN HE SAW HER NEXT.
SHE DID NOT GET HIM. SHE ALSO ADVISED THAT BETWEEN 0800 HRS
AND 1200 HRS STACKFIELD'AGAIN CALLED HER SEVERAL TIMES AND
THREATENED TO HURT HER. SHE BELIEVES HE IS STAYING WITH A
JEN LOPIANO IN CARLISLE.
MS. BRIDGE WAS ADVISED THAT WHEN WE LOCATE STACKFIELD,
THAT HE WOULD BE ARRAINGED ON CHARGES OF VIOLATING THE PFA.
.'.~
-~----~-----------------------------------------------.---------------------
MLDDLESEX TWP POLICE
CRIME REPORT
Date 04/26/94
MPD Inc # 0353-94
CO Inc #
------------------------------------------------------------------------------.
Offense: FALSE IMPRISONMENT
Sec # 2903
Status: CA
------------------------------------------------------.------------------------
Ucr Code: 20
Co/Twp Code: 21/206
Premise R
Officer# 2
-------------------------------------------------------------------------------
Date Occurred: 04/22/94
Day: FRI-
Time: 0352 -
-------------------------------------------------------------------------------
Location
1226 CLAREMONT DR
_________________________________________________________________w"_____________
Discovered
By:
Last BRIDGE First
Address 1226 CLAREMONT RD
State PA Zip 17013
DEBORAH Middle W
City CARLISLE
Phone (717) 258-0890
-------------------------------------------------------------------------------
Discover Date : 04/22/94
Notified Date : 04/22{94
Time 0352
Time 0352
Value $
o
----------------------.--------------------------------------------------------
VICTIM:
Last BRIDGE First DEBORAH
Address 1226 CLAREMONT DR
State PA Zip 17013 Phone
Middle W
City CARLISLE
(717) 258-0890
*Race W Sex P DOB OS/25/66
Employer ~MPr.nVF.n
Age 27 SSN# 196-48-2679
Work Phone ( )
-------------------------------------------------------------------------------
ARREST:
Last STACKFIELD First MILTON
Address 1226 CLAREMONT RD
State PA Zip 17013 Phone
Middle L
City CARLISLB
(717) 258-0890
*Race B
Employer
Height
Sex M nOB 12/26/57
UNEMPLOYED
Weight Hair
Age 36 SSN# 201-50-3758
Work Phone ( )
Eyes Complexion
-------------------------------------------------------------------------------
ON 4-22-94 AT 0352 HRS, I RECEIVED INFORMATION TO GO TO
1226 CLAREMONT RD FOR A PROTECTION FROM ABUSE ORDER VIOLA-
TION. I WAS ASSISTED ON THE CALL BY OFFICER PETERSON OF
NORTH MIDDLETON TWP. PD.
WHILE ENROUTE TO THE RESIDENCE I WAS ADVISED BY COUNTY
CONTROL THAT STACKFIELD WAS IN THE RESIDENCE AND BRIDGE WAS
WHISPERING INTO THE PHONE TELLING THEM WHAT WAS GOING ON.
AS WE APPROACHED THE RESIDENCE, WE WERE INFORMED THAT
STACKFIELD HAD TAKEN BRIDGE FROM THE RESIDENCE. PETERSON
REPORTED HE WAS PREPARING TO STOP A VEHCILE HE HAD OBSERVED
LEAVING THE RESIDENCE. PETERSON REPORTED THE VEHICLE HAD
TRHEE OCCUPANTS. COUNTY CONTROL ADVISED US THERE SHOULD BE
2 BLACK MALES AND THE VICTIM BRIDGE IN THE VEHICLE. I PRO-
CEEDED TO THE AREA OF THE STOP AND SPOKE WITH BRIDGE. SHE
SAID STACKFIELD HAD FORCED HIS WAY INTO THE HOUSE AND WAS
ARGUING WITH HER AND ATTEMPTING TO FORCE HER TO LEAVE WITH
WITH HIM. BRIDGE REPORTED SHE HAD TOLD HIM SEVERAL TIMBS
TO LEAVE THE HOUSE AND THAT SHE DID NOT WANT TO GO WITH HIM.
STACKFIELD TOOK HER BY THE WRIST AND FORCED HER FROM THE
RESIDENCE AND INTO THE VEHICLE. BRIDGE SAID A PROCTECTION
FROM ABUSE ORDER HAD BEEN SIGNED ON APRIL 7, 1994 BY JUDGE
..-;
BOFl"BR. THB ORDBR STATBD THAT STACJCPIBLD 1fA8
TO PUT HBR IN FnAR OP PHYSICAL ABOSB.
STACJtPIBLD WAS PLACED UNOBR ARREST.
-.
--------------------------------------- .~~~~
~i~;~~;;~--i--J-:~~ _~_:~_~~-------------~~~~~:~:~
____________~~ Cl ___~
.
. -
,
Nancy M. Small, A.C.S.W.
EDUCATION:
Master of Social Work. Templc University
December 1987
Bachelor of Social Work. Shippensburg University
Deccmbcr 1975
PROFESSIONAL EXPERIENCE:
Social Workcr in Private Clinical ''ractice
2/91 to ''resent
Franco Psychological Associatcs, Carlisle, PA
Provide outpatient therapy to familics. individuals
and couplcs.
Mental Health Consultant
9/91 to 5/92
Head Start Program. Cumbcrland Cowlty
Providcd direct intelVention and consultation to children.
familics and staff.
Clinical Evaluator/Outpatientlllerapist
12/87 to 2191
Stevens Center. Carlisle, PA
Providcd group. individual, play and family therapy. Provided
clinical assessments. bricf intelVcntions, and treatment planning
to clients requcsting sclVices at this community mental health
center. SelVed as Acting Director of Outpatient SelVices.
Counseling Coordinator
3/85 to 12/87
Women In Necd, Chambersburg, PA
Provided group and individual cowlscling to victims of domestic
violcncc.
Program dcvclopment and stafT supclVision.
Caseworker
4/78 to 9/81
Cumbcrland County Officc of Aging, Carlislc PA
Asscsscd nccds of e1dcdy and arrangcd selViccs to maintain
indepcndcnt living. SupclViscd studcnt intems.
~ PETITIONER'S
IL
Cascworkcr
9/75 to 4/78
Cumbcrland County Nursing Homc. Carlislc. PA
Coordinated admissions and social sClVicc nccds of rcsidcnts.
~~......~, I,
Page Two
Nancy M. Small, AC.S.W.
SPECIALIZED TRAINING:
Domestic violence, sexual abuse, family therapy, relationship
enhancement skills, play and filial therapy, social skill
development with children, divorce adjustment, custody
evaluation.
Detail provided on request.
PROFESSIONAL AFFILIATIONS:
PA Social Work License
NASW Member
ACSW Member
REFERENCES:
Available on request.
JODY L. BRIDGE,
Plaintiff
.
.
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
.
.
V.
.
.
DEBORAH W. BRIDGE,
Defendant
: CIVIL ACTION - CUSTODY
NO. 94-2347 CIVIL TERM
IN RE: CONTINUED HEARING
ORDER OF COURT
AND NOW, this 28th day of December, 1994, the
Court continues this hearing until Friday, January 6th, 1995, at
9:30 a.m. Each party may call any additional witnesses that
they wish to call at that time.
By the court,
Barbara J. Yunis, Esquire
For the Plaintiff
Joan C. carey, Esquire
For the Defendant
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JODY L. BRIDGE, . IN THE COURT OF COMMON PLEAS OF
.
Plaintiff . CUMBERLAN~ COUNTY, PENNSYLVANIA
.
.
.
V. :
.
.
DEBORAH W. BRIDGE, CIVIL ACTION - CUSTODY
Defendant NO. 94-~347 CIVIL TERM
ORDER OF COURT
AND NOW, this 6th day of January, 1995, the
testimony being completed in this custody case, the Court has
indicated that I will write a brief opinion which will decide
where the children should go. Pending the filing of that
opinion, the Court directs that the parties comply with the
existing schedule of custody and partial custody that they have
been using up until this particular time.
By the Court,
\~LJ\-=~ .~1~
Harold E. Sheely, P.J.
--
Barbara J. Yunis, Esquire
For the Plaintiff
Joan C. Carey, Esquire
For the Defendant
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AND NOW, this
IN RE: CUSTODY
BEFORE SHEELY. P.J.
JIDDER OF COURT
7, 2.,~1- day of FEBRUARY,
1995, the court
JODY L. BRIDGE
V
DEBORAH W. BRIDGE
a/k/a DEBORAH W. STACKFIELD
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
.
NO. 94-2347 CIVIL TERM
CIVIL ACTION - LAW
IN CUSTODY
hereby directs the following:
1. Jody Bridge and Deborah Stackfield shall share joint
legal custody of Kale K. Bridge and Brice E. Bridge.
2. Jody Bridge and Deborah Stackfield shall share physical
custody of Kale K. Bridge and Brice E. Bridge as follows:
a. Jody Bridge shall have physical custody of the two boys
from March 18, 1995 at noon to April 22, 1995 at noon. Deborah
Stackfield shall have physical custody from April 22, 1995, at
noon to May 20, 1995 at noon. Jody Bridge shall have custody
from May 20, 1995 at noon to June 17, 1995 at noon. Deborah
Stackfield shall have custody from June l7, 1995 at noon to July
22, 1995 at noon. Jody Bridge shall have custody from July 22,
1995 at noon to August 19, 1995 at noon.
b. The parent not having custody during the appropriate one
(1) month period shall have partial custody of the boys each
Wednesday evening from the close of school to 8:30 p.m. and that
parent shall return the boys at that time to the parent having
custody. Also, the non-custodial parent shall have partial
custody every other weekend from the close of school on Friday to
Sunday at 6:00 p.m., and when school is completed, from Friday at
5:00 p.m. to Sunday at 6:00 p.m. The first weekend shall be the
first weekend after the change of custody is completed. The
parent having partial custody for weekends shall pick up and
return the children to the parent having custody.
c. There shall be no change of custody for Holidays.
d. Another hearing is set for Wednesdav. Auaust 16. 1995.
at 1:00 D.m.. Courtroom # 1. I will hear testimony at that
hearing on what has happened since the date of this order and
whether the joint physical custody should be changed at that
time. I would also want to know whether the school districts of
each parent have any problem with the children attending full
time in their district under a shared physical custody
arrangement.
By the Court,
Lf""j rfh/
H roId E. Sheely, P.J.
Barbara Yunis, Esquire
For the natural father
Joan Carey, Esquire
For the natural mother
Cof........ 'j.v<"-'
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JODY L. BRIDGE
: IN THE COURT OF COMMON PLEAS OF
: CUMBERLAND COUNTY, PENNSYLVANIA
:
V
.
.
DEBORAH W. BRIDGE
a/k/a DEBORAH W. STACKFIELD
: NO. 94-2347 CIVIL TERM
CIVIL ACTION - LAW
IN CUSTODY
IN RE: CUSTODY
BEFORE SHEELY. P.J.
OPINION AND ORDER OF COURT
HISTORY
Plaintiff, age thirty (30) seeks full physical custody of
his two children, Kale K. Bridge, born April 7, 1986, and Brice
Elliot Bridge, born September 21, 1987. The two children are now
in the custody of his ex-wife, Deborah Bridge Stackfield, age
twenty eight (28). The last hearing was held on January 6, 1995.
FINDINGS OF FACT
l. The parties here were married in 1984, separated in 1988
and are now divorced.
2. Plaintiff married his present wife Lisa, aged thirty-two
(32) in 1990. Living with them are her two daughters ages eleven
(ll) and six (6) and one daughter born to their marriage, Kara,
age three (3). Lisa does not work outside the home.
3. Deborah had a son born out of wedlock, Ty, aged three
(3). He and the two boys in question also reside with her. She
NO. 94-2347 CIVIL TERM
married Milton Stackfie1d on May 4, 1994. Prior to marriage they
lived together for about 2 1/2 years. Mr. Stackfield has three
(3) sons, seven (7), five (5), and three (3), who reside with
their mother. Mrs. Stackfield is employed at a 9 to 5 job.
4. Pursuant to a marriage settlement agreement signed by
the parties on November 6, 1989, paragraph 12, defendant mother
was given physical custody of the boys.
5. Milton Stackfield has had Inpatient Treatment
experiences for crack cocaine abuse and has relapsed after the
first four (4) treatment programs.
6. Although Milton Stackfield was convicted of one count of
simple assault in 1977, we do not believe that to be relevant in
this custody action.
a. On April 19, 1994, Milton Stackfield pleaded guilty to
two counts of delivery of cocaine here in Carlisle Borough, and
was sentenced on May 3l, 1994 to a 4-23 month sentence in
Cumberland County Prison. He was paroled on these charges
September l, 1994.
b. November 1994, Milton Stackfield pleaded guilty to a
delivery of cocaine in Carlisle. He was sentenced on December
20, 1994 to a 4-22 month county sentence.
c. On December I, 1994, Milton Stackfield was arrested in
Carlisle Borough for three (3) deliveries of cocaine, the dates
being March 17, 1994, March 23, 1994, and March 31, 1994. He was
released on bail December 9, 1994.
2
NO. 94-2347 CIVIL TERM
7. Milton Stackfield has abused Deborah Stackfield on the
following times and places:
a. On March 14, 1994, about 2:00 p.m. Deborah called County
Control from l226 Claremont Road and said her phone was cut off.
Police went there and found no one at the residence. About
fifteen (l5) minutes later, Deborah again called County Control
and said Mr. Stackfie1d beat her up and charges of assault were
filed at a District Justice.
b. On April 7, 1994, a protection from abuse order was
obtained against Mr. Stackfie1d.
c. On April 20, 1994, at 1207 hours Deborah called the
police and said she had been assaulted by Mr. Stackfie1d at their
residence at l226 Claremont Road
d. On April 21, 1994, Deborah called police and said Mr.
Stackfie1d called her at her residence at 1226 Claremont Road six
or seven times between midnight and 5:00 a.m. and said he would
kill her unless she would come and get him.
e. April 22, 1994, at 3:52 a.m., Deborah called for help
from the residence at 1226 Claremont Drive. She was found in a
car with Mr. Stackfi1ed and told police Stackfie1d forced his way
into her house and forcibly removed her and put her into the
vehicle.
f. June 14, 1994, Mr. Stackfie1d slapped Deborah several
times, pushed her into a wall and struck her with his fist
causing a cut along her left eye. She was treated at the
3
NO. 94-2347 CIVIL TERM
Carlisle Hospital Emergency Room. This occurred at the residence
where the parties were living, 1226 Claremont Road.
8. Both parties now have adequate living space for full
physical custody of the boys. The mother's home has more ground
around the house for the boys to play.
DISCUSSION
The legislature has set forth factors for the court to
consider in making an award of custody in 23 Pa.C.S.A. 5303:
(a) General rule.-In making an
order for custody, partial custody
or visitation to either parent, the
court shall consider, among other
factors, which parent is more
likely to encourage, permit and
allow frequent and continuing
contact and physical access between
the noncustodial parent and the
child. In addition, the court
shall consider each parent and
adult household member's present
and past violent or abusive conduct
as defined under the act of October
7, 1976 (P.L. 1090, No. 2lB), known
as the Protection From Abuse Act.
. . .
(d) Sole custody.-The court
shall award sole custody when it is
in the best interest of the child.
In this case, I believe the evidence indicates that Mr. Bridge
and his present wife are good parents, responsible people, and
would be good full time custodial parents for Kale and Brice. I
likewise believe the evidence would indicate that Deborah
Stackfield has been a good parent and if living by herself would
be a good parent and could continue full time custody of the two
boys. She also has caring parents who live close and have
4
NO. 94-2347 CIVIL TERM
assisted her greatly since she has had sole custody of the two
boys. The evidence, however, casts serious doubt on whether she
should be permitted to retain full time phyeical custody of the
boys and still live with Milton Stackfield. Mr. Stackfield has
physically beaten her in the home where the children reside and
has physically removed her from the house. He is a convicted
drug dealer three times from sale of cocaine. He has an
additional three (3) charges for sale of cocaine pending. After
the beatings and his sentences for selling cocaine, she then
married Mr. Stackfield. Raising the boys in the same household
and environment with a person such as Mr. Stackfield certainly
puts the good judgment of Mrs. Stackfield at issue.
There is evidence in the record to indicate the boys are
aware of Mr. Stackfield selling drugs in the community. There is
evidence in the record to also indicate the boys were aware of
some of the abuse incidents involving their mother. I spoke to
both boys in Chambers with counsel present. Both boys have
learning difficulties to some extent and it was very difficult to
get responsive answers in many instances which I know from past
experience is not unusual. Both boys said they liked Mr.
Stackfield.
The father and mother of the boys live close to each other.
I believe generally the evidence would indicate that the parties
have tried to comply with the terms of the present arrangement
involving periods of partial custody and will comply with any
5
NO. 94-2347 CIVIL TERM
court o~der involving custody. The children can finish the
school year regardless of which parent has physical custody.
The likelihood of more jail time for Mr. Stackfield is great
when he is sentenced on the present drug charges. It also
remains to be seen how well his present treatment programs will
terminate drug involvement and physical abuse of Mrs. Stackfield.
I believe the following order to be in the best interest of the
children at this time.
ORDER OF COURT
AND NOW, this /1.:; nil day of FEBRUARY, 1995, the court
hereby directs the following:
1. Jody Bridge and Deborah Stackfield shall share joint
legal custody of Kale K. Bridge and Brice E. Bridge.
2. Jody Bridge and Deborah Stackfield shall share physical
custody of Kale K. Bridge and Brice E. Bridge as follows:
a. Jody Bridge shall have physical custody of the two boys
from March lB, 1995 at noon to April 22, 1995 at noon. Deborah
Stackfield shall have physical custody from April 22, 1995, at
noon to May 20, 1995 at noon. Jody Bridge shall have custody
from May 20, 1995 at noon to June l7, 1995 at noon. Deborah
Stackfield shall have custody from June l7, 1995 at noon to July
22, 1995 at noon. Jody Bridge shall have custody from July 22,
1995 at noon to August 19, 1995 at noon.
b. The parent not having custody during the appropriate one
(ll month period shall have partial custody of the boys each
6
/s/ Harold E. Sheelv
Harold E. Sheely, P.J.
NO. 94-2347 CIVIL TERM
Wednesday evening from the close of school to 8:30 p.m. and that
parent shall return the boys at that time to the parent having
custody. Also, the non-custodial parent shall have partial
custody every other weekend from the close of school on Friday to
Sunday at 6:00 p.m., and when school is completed, from Friday at
5:00 p.m. to Sunday at 6:00 p.m. The first weekend shall be the
first weekend after the change of custody is completed. The
parent having partial custody for weekends shall pick up and
return the children to the parent having custody.
c. There shall be no change of custody for Holidays.
d. Another hearing is set for Wednesdav. Auaust 16. 1995.
at 1:00 p.m.. Courtroom # 1. I will hear testimony at that
hearing on what has happened since the date of this order and
whether the joint physical custody should be changed at that
time. I would also want to know whether the school districts of
each parent have any problem with the children attending full
time in their district under a shared physical custody
arrangement.
By the Court,
Barbara J. Yunis, Esquire
For the natural father
Joan Carey, Esquire
For the natural mother
IBId
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JODY L. BRIDGE,
Plaintiff
IN THE COURT OF COMMON PLEAS OF
vs.
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 94-2347 CIVIL TERM
DEBORAH W. BRIDGE,
a/k/a DEBORAH STACKFIELD
Defendant
CUSTODY
AND NOW, this
yr ORDER
'2~1 - day of
June, 1995, upon
consideration of the Motion to Withdraw as Counsel, Joan Carey of
Legal Services, Inc. is granted permission to withdraw as counsel
for the defendant in the above captioned case.
By the Court,
'~ (CC-(\ )f~- /f~~/
H rold E. Sheely, J.
" '
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56. IiI' LIT 9 zz ~nr
JODY L. BRIDGE,
Plaintiff
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 94-2347 CIVIL TERM
vs.
DEBORAH W. BRIDGE,
alkla DEBORAH STACKFIELD
Defendant
CUSTODY
MOTION TO WITHDRAW AS COUNSEL
Joan Carey of Legal Services, Inc., counsel for the
defendant, Deborah Stackfield (formerly Bridge), respectfully
requests leave to withdraw as Defendant's counsel for the
following reasons:
1. On or about May 18, 1994, Jody L. Bridge filed a
Petition for Special Relief requesting temporary custody. This
request was denied and the matter of custody was referred to the
Custody Conciliator.
2. On or about May 18, 1994, Legal Services, Inc. agreed to
represent the defendant, who at that time was financially
eligible for Legal Services' representation.
3. A Custody Conciliation Conference was held on July 21,
1994. On August 9, 1994, the Conciliator stated a hearing was
necessary and the children should remain in the primary custody
of the Mother in accordance with the parties' November 6, 1989,
agreement.
4. After the hearing, the Court issued an Opinion and Order
on or about February 22, 1995, granting Jody Bridge and Deborah
Stackfield shared physical custody of Kale K. Bridge and Brice E.
Bridge. The Court scheduled a hearing for Wednesday, August 16,
.'
I '."
..........--..
1995, at 1:00 p.m., Courtroom # 1, to hear testimony on what has
happened since the date of this order and to determine whether
the joint physical custody should be changed.
5. Good cause exists for Legal Services' withdrawal as
counsel since on or about May 19, 1995, Legal Services
redetermined Ms. Stackfield's eligibility for services, and
determined that her income exceeded Legal Services' financial
eligibility guidelines. At this time Ms. Stackfield was informed
of her ineligibility and was advised to that she should retain
private counsel.
6. On or about June 14, 1995, Legal Services reiterated the
status of the case by sending a letter to Ms. Stackfield. See
Exhibit A attached and incorporated by reference.
7. Legal Services' withdrawal can be accomplished without a
material adverse effect on the interests of the defendant because
a hearing is not scheduled until August 16, 1995, and Legal
Services has agreed to cooperate with the defendant's counsel.
WHEREFORE, Legal Services, Inc. asks this Court to grant
this Motion to Withdraw as Counsel in the above-captioned case
and any other relief which is just and proper.
Respectfully submitted,
Jt..,-" Jl-dJ'GC~L
. oan Carey
.< LEGAL SERVICES, INC.
8 Irvine Row
Carlisle, PA 17013
(717) 243-9400
',._~,,"'f
LEGAL SERVICES, INC.
II Irvine Row
Carlisle. Pennsylvania 171113
(717) 243.'I4IKI
Fax (717) 243.1I1126
West Shore (717) 7611.11475
rflllUIII rl""LaIlc
(1IambtntMltl- PrIlMyM." 17311
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June 14, 1995
Deborah Stackfield
1226 Claremont Road
Carlisle, PA 17013
RE: Custody
Dear Deborah,
This letter confirms that we informed you on May 19, 1995,
that you were ineligible for Legal Services assistance in your
custody case since you no longer meet the financial eligibility
guidelines. I reiterate that you must contact an attorney to
represent you in your custody case as soon as possible since your
hearing is on August 16, 1995, at 1:00 p.m. in Courtroom II.
I would be happy to discuss the history of your case with
the attorney you obtain if you sign the release enclosed and mail
it back to me in the self-addressed stamped envelope. I have
enclosed a copy of the Motion to Withdraw as Counsel which I will
file with the Court this week. Thank you for your cooperation in
this matter and throughout your custody case.
Sincerely,
LEGAL SERVICES, INC.
~ 'l<.i!),tvr.<-(//
('fo:~ Carey ?I
Attorney-at-Law
Exhibit A
SERVING ADAMS. CUMBERLAND. FRANKl.IN AND FULTON COUNTIES
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JODY L. BRIDGE,
Plaintiff
v.
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 94-2347 CIVIL TERM
DEBORAH W. STACKFIELD,
Defendant
CIVIL ACTION - IN CUSTODY
AND NOW,
ORDER OF COURT
Y I 'Jc:dC) 8
upon consideration of the
attached Complaint, it is hereby directed that the parties and
their respective counsel appear before \-\U\::eC-\- '/.... G\ \\"0,,-/, EsCl.
the conciliator, at -\\-c L\~f\.(u~dJ\\(Iffh'f\c:.rdCa Cu..dl""'OJs.c:.on
the \'2) day of ~\..J(\c.:.. , 1998 at ;?,: SOq.m., for a
Pre-Hearing Custody Conference. At such conference, an effort
will be made to resolve the issues in dispute; or if this cannot
be accomplished, to define and narrow the issues to be heard by
the court, and to enter into a temporary order. All children age
five or older shall also be present at the conference. Failure
to appear at the conference may provide grounds for entry of a
temporary or permanent order.
FOR THE COURT:
~
By: -1-(\~~J\.i A.(.\L
Custody Conciliator ~
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT
HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE
SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
CUMBERLAND COUNTY BAR ASSOCIATION
2 LIBERTY SQUARE
CARLISLE, PA 17013
(717) 249-3166
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JODY L. BRIDGE,
Plaint if f
v.
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 94-2347 CIVIL TERM
DEBORAH W. STACKFIELD,
Defendant
CIVIL ACTION - IN CUSTODY
PETITION FOR CUSTODY
AND NOW, comes the Petitioner Deborah W. Stackfield by and
through her attorneys Saidis, Shuff & Masland and respectfully
avers the following:
1. The Petitioner is Deborah W. Stackfield, an adult
individual residing at 1226 Claremont Road, Carlisle,
Cumberland County, Pennsylvania 17013.
2. The Respondent is Jody L. Bridge, an adult individual
residing at P.O. Box 352, Boiling Springs, Cumberland County,
Pennsylvania 17007.
3. Petitioner seeks custody of the following child:
Name
Present Residence
D.O.B.
Kale C. Bridge
1226 Claremont Road
Carlisle, PA 17013
4-7-86
Brice E. Bridge
1226 Claremont Road
Carlisle, PA 17013
9-21-87
The children were not born out of wedlock.
SAIDlS.
SHUFF &
MASLAND
A1TORNEY5.AT.uW
The children are presently in a shared custody situation
by a prior Court Order dated February 22, 1995. A copy of the
Court Order is attached hereto and made a part hereof marked as
26 W. 1II&h SI'Od
1:0,11.1.. PA
Exhibit "A".
During the past five years, the children have resided with
the following persons and at the following addresses:
Persons
Addresses
1226 Claremont Road
Carlisle, PA 17013
Dates
Deborah W. Stackfield
From July
1988 to
Feb. 1995
Deborah W. Stackfield &
Jody L. Bridge in a
shared custody situation
pursuant to the Court
Order dated February
22, 1995
1226 Claremont Road
Carlisle, PA 17013
and
P.O. Box 352
Boiling Springs, PA
17007
From Feb.
1995 to the
Present
The mother of the children is the Petitioner, Deborah W.
Stackfield, residing at 1226 Claremont Road, Carlisle, PA
17013.
She is married.
The father of the children is the Respondent, Jody L.
Bridge, residing at P.O. Box 352, Boiling Springs, PA 17007.
He is married.
4. The relationship of Petitioner to the children is that
of natural mother. Petitioner currently resides with her
husband, Milton Stackfield and her son, Ty Winston.
5. The relationship of Respondent to the children is that
of father. The father currently resides with his wife, Lisa
Bridge, her two children, Mandy Darhour and Hanna Darhour and
their child, Kara Bridge.
6. The best interest and permanent welfare of the
SAID IS,
SHUFF &
MAS LAND
ATrORHEYS'AT'UW
26 W. "ISh slr..1
Co,II.t., PA
children will be served by granting relief requested because
the children have expressed their interest in residing solely
with mother; the living arrangements at father's house are too
crowded; the children are presently in a counselling situation,
and said counsellor has advised that mother is best served to
have primary physical custody of the children.
7. Each parent whose parental rights to the children have
not been terminated and the person who has physical custody of
the children have been named as parties to this action. All
other persons, named below, who are known to have or claim a
right to custody or visitation of the children will be given
notice of the pendency of this action and the right to
intervene: N/A
WHEREFORE, Plaintiff requests the court grant her primary
physical custody of the children subject to periods of partial
physical custody in the Respondent.
Respectfully submitted,
SAlDIS, SHOFF & MASLAND
Dated:
Lf- 11 .q~
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Johnrn J. eilX, Esquire
26 . Hi Street
Carlisle, PA 17013
717-243-6222
Attorney for Petitioner
SAlOIS.
SHUFF &
MASLAND
A~AT.uW
26 W. Hlsh SIr..1
Cull.I., P^
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JODY L. BRIDGE
V
DEBORAH W. BRIDGE
a/k/a DEBORAH W. STACKFIELD
.
.
.
.
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
.
.
.
.
.
.
NO. 94-2347 CIVIL TERM
.
.
":
AND NOW, this
: CIVIL ACTION - LAW
. IN CUSTODY
IN RB: CUSTODY
BEFORE SHEELY. P.J.
~DER OF COURT
t.. 2..:":/--- day of FE~RUARY,
hereby directs the fOllowing:
1995, the COUrt
1. Jody arid.e end Deborah Staekfield nhnll .hare joint
le..l eo.tody of 'ale .. arid.o aod arieo e. arid.o.
2. JOdy arid.o and Deborah Staekfield .hall .hare phy.ie"
eo.tody of 'alo .. arid.o and ariee E. arid.e a. fOlIo""
a. Jody arid.e ohall have Phy.ieal eo.tody of the two boy.
..
from March 18, 1995 at noon to
Stackfield ~hall have Physical
::'.Ilo
.K
April 22, 1995 at noon. Deborah
,
custOdy from.~pril 22, 1995, at
noon to May 20, "., at noon. Jody arid.e 'ball have eo.tody
froo May 20, "" at noon to Jone 17, "" at noon. Oeborah
Staekfield 'hall have eo.tody fron Jone 17, "" at noon to JOly
22, I." at noon. Jody arid.e 'hall have eo.tody froo JOly 22,
1995 at noon to August 19, 1995 at noon.
b. The parent not havin. eo.tody dorin. the appropriate one
rl) month Period 'hall have Partial eo.tody of the boy. eaeh
'edne.day evenin. froo the elo.e of 'ehool to 8.JO P.m. and that
parent .h"1 retorn the boy. at th,t time to the parent h,vi..
EXHIBIT "A"
""-...-...
JODY L. BRIDGE
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
'::
.
.
V
.
.
.
.
DEBORAH W. BRIDGE
a/k/a DEBORAH W. STACKFIELD
.
.
: NO. 94-2347 CIVIL TERM
.
.
: CIVIL ACTION - LAW
.
.
: IN CUSTODY
IN RE: CUSTODY
BEFORE SHEELY. P.J.
OPINION AND ORDER OF COURT
HISTORY
Plaintiff, age thirty (30) seeks full physical custody of
his two children, Kale K. Bridge, born April 7, 1986, and Brice
Elliot Bridge, born September 2l, 1987. The two children are now
in the custody of his ex-wife, Deborah Bridge Stackfield, age
twenty eight (28). The last hearing was held on January 6, 1995.
FINDINGS OF FACT
1. The parties here were married in 1984, separated in 1988
and are now divorced.
2. Plaintiff married his present wife Lisa, aged thirty-two
(32) in 1990. Living with them are her two daughters ages eleven
(11) and six (6) and one daughter born to their marriage, Kara,
age three (3). Lisa does not work outside the home.
3. Deborah had a son born out of wedlock, Ty, aged three
(3). He and the two boys in question also reside with her. She
NO. 94-2347 CIVIL TERM
married Milton Stackfield on May 4, 1994. Prior to marriage they
lived together for about 2 l/2 years. Mr. Stackfield has three
(3) sons, seven (7), five (5), and three (3), who reside with
their mother. Mrs. Stackfield is employed at a 9 to 5 job.
4. Pursuant to a marriage settlement agreement signed by
the parties on November 6, 1989, paragraph 12, defendant mother
was given physical custody of the boys.
5. Milton Stackfield has had Inpatient Treatment
experiences for crack cocaine abuse and has relapsed after the
first four (4) treatment programs.
6. Although Milton Stackfield was convicted of one count of
simple assault in 1977, we do not believe that to be relevant in
this custody action.
a. On April 19, 1994, Milton Stackfield pleaded guilty to
two counts of delivery of cocaine here in Carlisle Borough, and
was sentenced on May 3l, 1994 to a 4-23 month sentence in
Cumberland County Prison. Be was paroled on these charges
September 1, 1994.
b. November 1994, Milton Stackfield pleaded guilty to a
delivery of cocaine in Carlisle. Be was sentenced on December
20, 1994 to a 4-22 month county sentence.
c. On December l, 1994, Milton Stackfield was arrested in
Carlisle Borough for three (3) deliveries of cocaine, the dates
being March 17, 1994, March 23, 1994, and March 31, 1994. Be was
released on bail December 9, 1994.
2
NO. 94-2347 CIVIL TERM
7. Milton Stackfield has abused Deborah Stackfield on the
following times and places:
a. On March l4, 1994, about 2:00 p.m. Deborah called County
Control from 1226 Claremont Road and "said her phone was cut off.
Police went there and found no one at the residence. About
fifteen (15) minutes later, Deborah again called County Control
and said Mr. Stackfield beat her up and charges of assault were
filed at a District Justice.
b. On April 7, 1994, a protection from abuse order was
obtained against Mr. Stackfield.
c. On April 20, 1994, at 1207 hours Deborah called the
police and said she had been assaulted by Mr. Stackfield at their
residence at 1226 Claremont Road
d. On April 2l, 1994, Deborah called police and said Mr.
Stackfield called her at her residence at l226 Claremont Road six
or seven times between midnight and 5:00 a.m. and said he would
kill her unless she would come and get him.
e. April 22, 1994, at 3:52 a.m., Deborah called for help
from the residence at 1226 Claremont Drive. She was found in a
car with Mr. Stackfiled and told police Stackfield forced his way
into her house and forcibly removed her and put her into the
vehicle.
f. June 14, 1994, Mr. Stackfield slapped Deborah several
times, Pushed her into a wall and struck her with his fist
causing a cut along her left eye. She was treated at the
3
~
NO. 94-2347 CIVIL TERM
Carlisle Hospital Emergency Room. This occurred at the residence
where the parties were living, l226 Claremont Road.
8. Both parties now have a~equate living space for full
physical custody of the boys. The mother's home has more ground
around the house for the boys to play.
DISCUSSION
The legislature has set forth factors for the court to
consider in making an award of custody in 23 Pa.C.S.A. 5303:
(aj General rule.-In making an
order for custody, partial custody
or visitation to either parent, the
court shall consider, among other
factors, which parent is more
likely to encourage, permit and
allow frequent and continuing
contact and physical access between
the noncustodial parent and the
child. In addition, the court
shall consider each parent and
adult household member's present
and past violent or abusive conduct
as defined under the act of October
7, 1976 (P.L. 1090, No. 218), known
as the Protection From Abuse Act.
. . .
(d) Sole custodY.-The court
shall award sole custody when it is
in the best interest of the child.
In this case, I believe the evidence indicates that Mr. Bridge
and his present wife are good parents, responsible people, and
would be good full time custodial parents for Kale and Brice. I
likewise believe the evidence would indicate that Deborah
Stackfield has been a good parent and if living by herself would
be a good parent and could continue full time custody of the two
boys. She also has caring parents who live close and have
4
NO. 94-2347 CIVIL TERM
assisted her greatly since she has had sole custody of the two
boys. The evidence, however, casts serious doubt on whether she
should be permitted to retain full time physical custody of the
boys and still live with Milton Stackfield. Mr. Stackfield has
physically beaten her in the home where the children reside and
has physically removed her from the house. Be is a convicted
drug dealer three times from sale of cocaine. He has an
additional three (3) charges for sale of cocaine pending. After
the beatings and his sentences for selling cocaine, she then
married Mr. Stackfield. Raising the boys in the same household
and environment with a person such as Mr. Stackfield certainly
puts the gOod jUdgment of Mrs. Stackfield at issue.
There is evidence in the record to indicate the boys are
aware of Mr. Stackfield selling drugs in the community. There is
evidence in the record to also indicate the boys were aware of
some of the abuse incidents involving their mother. I spoke to
both boys in Chambers with counsel present. Both boys have
learning difficulties to some extent and it was very difficult to
get responsive answers in many instances which I know from past
experience is not unusual. Both boys said they liked Mr.
Stackfield.
The father and mother of the boys live close to each other.
I believe generally the evidence Would indicate that the parties
have tried to comply with the terms of the present arrangement
involving periods of partial custody and will comply with any
5
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NO. 94-2347 CIVIL TERM
court order involving custody. The children can finish the
school year regardless of which parent has physical custody.
The likelihood of more jail time for Mr. Stackfield is great
when he is sentenced on the present drug charges. It also
remains to be seen how well his present treatment programs will
terminate drug involvement and physical abuse of Mrs. Stackfield.
I believe the following order to be in the best interest of the
children at this time.
ORDER OF COURT
AND NOW, this ~~ F/C~ day of FEBRUARY, 1995, the court
hereby directs the fOllowing:
l. Jody Bridge and Deborah Stackfield shall share joint
legal custody of Kale K. Bridge and Brice E. Bridge.
2. Jody Bridge and Deborah Stackfield shall share physical
custody of Kale K. Bridge and Brice E. Bridge as follows:
a. Jody Bridge shall have physical custody of the two boys
from March lB, 1995 at noon to April 22, 1995 at noon. Deborah
Stackfield shall have physical custody from April 22, 1995, at
noon to May 20, 1995 at noon. Jody Bridge shall have custody
from May 20, 1995 at noon to June 17, 1995 at noon. Deborah
Stackfield shall have custody from June 17, 1995 at noon to July
22, 1995 at noon. Jody Bridge shall have custody from July 22,
1995 at noon to August 19, 1995 at noon.
b. The parent not having custoay during the appropriate one
(1) month period shall have partial custody of the boys each
6
,
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NO. 94-2347 CIVIL TERM
Wednesday evening from the close of school to 8:30 p.m. and that
parent shall return the boys at that time to the parent having
custody. Also, the non-custodial parent shall have partial
custody every other weekend from the close of school on Friday to
Sunday at 6:00 p.m., and when school is completed, from Friday at
5:00 p.m. to Sunday at 6:00 p.m. The first weekend shall be the
first weekend after the change of custody is completed. The
parent having partial custody for weekends shall pick up and
return the children to the parent having custody.
c. There shall be no change of custody for HOlidays.
d. Another hearing is set for Wednesdav. Auaust 16. 1995.
at 1:00 p.m.. Courtroom # 1. I will hear testimony at that
hearing on what has happened since the date of this order and
whether the joint physical custody should be changed at that
time. I would also want to know whether the school districts of
~
each parent have any problem with the children attending full
time in their district under a shared physical custody
arrangement.
By the Court,
Barbara J. Yunis, Esquire
For the natural father
/s/ Harold E. Sheelv
Harold E. Sheely, P.J.
Joan Carey, Esquire
For the natural mother
:ald
7
custOdy. Also, the non-cUstodial parent shall have partial
CUstody every other weekend from the close of school on Friday to
Sun..y nt "00 P.m., nn. when echool ie complete., fr.. Fri.ey .t
5'00 p.m. to Sun..y et "00 p.m. The firet Weekeo. eh." be the
first weekend after the change of custody is completed. The
parent having partial custody for weekends shall pick up and
return the children to the parent having CustOdy.
c. There shall be no change of custody for HOlidays.
d. Another hearing is set for Hednesdav. Auaust 16. 1995L
~t 1:00 c.m.. Courtroom, 1. I will hear testimony at that
heerio. on wh.t h.e h.ppene. eince the ..te of thie or.er and
whether the joint physical custody should be changed at that
time. I would "no w.ot to koow whether the echool .istricts of
each parent have any problem with the children attending full
time in their district under a shared physical custody
arrangement.
Barbara Yunis, Esquire
For the natural father
By the Court,
!rb~b&~
Harold E. Sheely, P.J.
Joan Carey, Esquire
For the natural mother
:sld
'T;~U'E COpy FRO,\-! RECORD
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ilr J "'J :.Ji ~: .;"iJ CCWf ell CJr:i:I~, Pa.
Th;s..(3~~ duy of"":l:!.~. '., 19..~~:-
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VERIFICATION
I verify that the statements made in this Petition for
Custody are true and correct. I understand that false
statements herein are made subject to the penalties of 18 Pa.
C.S. Section 4904, relating to unsworn falsification to the
authorities.
DATED:~-n-<{6
SAID IS,
SHUFF &
MAS LAND
ATTORNEYS-AT-LAW
26 W. IIIlh Slr..1
C.ulllh:, PA
LAW OPPlCI!S
SAIDlS, GUIDO, S~UF' "MASLAND
26 W, HIOH STREET JI09 MAi\.KET STREET
CARU5L\!, PA 1701~ CAMP HllJ.. PA 17011
PHONE (717) 24J-62Z2 PHONE (117) 737.340'
CERTII'II!D COPY:
~-Lf~
;?ZP
JODY L. BRIDGE,
Plaintiff
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 94-2347 CIVIL TEP~
v.
DEEORAH W. STACKFIELD,
Defendant
CIVIL ACTION - IN CUSTODY
ORDER OF COURT
AND NOW,
II C; \ Llq
upon consideration of the
attached Complaint, it is hereby directed that the parties and
their respective counsel appear before '~J(:c\ \ '/... 6\ \ro::-Jl E~ '
c- \""' r,\' . Q (Uyt)...~ \(llc.\ [~1 (CI_dhW)C-
the conciliator, at ~c '" \ \""t:u"\.,,) ('(),' on
the de;,. day of \"1::trvuf'--l ' 1994 at (f ,~OQ.m., for a
Pre-Hearing Custody Conference. At such conference, an effort
will be made to resolve the issues in dispute; or if this cannot
be accomplished, to define and narrow the issues to be heard by
the court, and to enter into a temporary order. All children age
five or older shall also be present at the conference. Failure
to appear at the conference may provide grounds for entry of a
temporary or permanent order.
FOR THE COURT:
Ey:
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT
HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE
SET FORTH BELOW TO FIND OUT WHERE YOU ~~ GET LEGAL HELP.
CUMBERLAND COUNTY BAR ASSOCIATION
2 LIBERTY SQUARE
CARLISLE, PA 17013
(717) 249-3166
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JODY L. BRIDGE,
Plaintiff
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
V.
CIVIL ACTION - LAW
DEBORAH W. STACKFIELD
Defendant
NO: 94-2347
IN CUSTODY
PETITION FOR CONCILLIATION
AND NOW COMES, Johnna J. Deily, Esquire on behalf of her
client, Deborah W. Stackfield and respectfully avers the
following:
1. The complaint for custody that was originally filed by
the Defendant, Deborah W. Stackfield.
2. On or about June 18, 1998 a custody conciliation hearing
was scheduled, whereby the parties did not agree on a change of
custody; however. they did agree to a custody evaluation of this
case.
3. On or about November 25, 1998, a custody evaluator, Dr.
Arnold T. Sheinvold, performed a custody evaluation.
4. The parties have still not reached an agreement for the
custody of the children.
WHEREFORE. the petitioner respectfully requests your
honorable court to schedule a custody conciliation hearing.
Respectfully submitted,
SAlOIS,
SHUFF &
MASLAND
,\ lTORNEl'S''\ T'U; W
26 W. 1fI&h Sir...
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JUN 2 3 1998t17
JODY L. BRIDGE,
Plaintiff
:IN THE COURT OF COMMON PLEAS OF
:CUMBERLAND COUNTY, PENNSYLVANIA
V
:CIVIL ACTION - LAW
DEBORAH W. STACKFIELD,
Defendant
:NO: 94-2347
:IN CUSTODY
COURT ORDER
AND NOW, this 7..~ f#. day of June, 1998, upon consideration
Conciliation Report, it is ordered and directed as follows:
of the attached Custody
I. The parties shall submit themselves, the minor children, the party's spouses or significant
others and any other pertinent people as required by the counsellor to a custody
evaluation to be perfonned by Dr. Arnold Schienvold. This evaluation shall be an
independent evaluation. Cost of the evaluation shall be shared equally between the
parties. The evaluator may share with the parties and counsel for the parties the results
of the evaluation. Upon conclusion of the evaluation and in the event at that time the
parties are unable to reach an agreement, either party may contact the Custody Coneiliator
for the scheduling of another Conference.
2. Pending further order of this Court, this Court's prior Order of February 22, 1995, shall
remain in effeet.
BY THE COURT,
ce:
Johnna J. Deily, Esquire
Bradford L. Gri me, Esquire
J.
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JODY L. BRIDGE,
Plaintiff
:IN THE COURT OF COMMON PLEAS OF
:CUMBERLAND COUNTY, PENNSYLVANIA
V
:CIVIL ACTION - LAW
DEBORAH W. STACKFIELD,
Defendant
:NO: 94-2347
:IN CUSTODY
Prior Judge: Harold E. Sheely
CONCII.IATION CONFERENCE SUMMARY REPORT
IN ACCORDANCE WITH THE CUMBERLAND COUNTY CIVIL RULE OF PROCEDURE
19I5.3-8(b), the undersigned Custody Conciliator submits the following report:
1. The pertinent infonnation pertaining to the children who are the subject of this litigation
is as follows:
Kale C. Bridge, born April 7, 1986; and Brice E. Bridge, born September 21, 1987.
2. A Conciliation Conference was held on June 18, 1998, with the following individuals in
attendance:
The Mother, Deborah W. Stackficld, with her counsel, Johnna J. Deily, Esquire; and the
Father, Jody L. Bridge, with his counsel, Bradford L. Griffie, Esquire.
3. The parties agreed to the entry of an Order in the fonn as attached.
Ct ~~I qg
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JODY L. BRIDGE.
Pluintiff
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY. PENNSYLVANIA
v
CIVIL ACTION - LAW
DEBORAH W. STACKFIELD.
Defendant
NO. 94 - 2347 CIVIL
IN CUSTODY
BY THE COURT,
.,.~
AND NOW. this Y day of March. 1999. the Conciliator being advised that the parties have
reached an agreement. the Conciliator relinquishes jurisdiction.
COURT ORDER
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MAY 25 1999)'L
JODY L. BRIDGE,
Plaintiff
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 94-2347
v.
DEBORAH W, STACKFIELD
Defendant
CIVIL ACTION - IN CUSTODY
AND NOW, this
ORDER OF COURT
).1) 'IL day of
flr171
Stipulation, it
, 1999, in
consideration of the attached
is hereby Ordered
and Directed that the parties shall share physical custody of
Kale C. Bridge and Brice E. Bridge. Mother shall have primary
physical custody of said children, subject to periods of
partial physical custody in father as evidenced by the attached
Stipulation.
BY 'rHE COURT,
SAlOIS,
SHUFF &
MAS LAND
A~AT.uW
26 W. "'sh Sir..,
c.,II,I., PA
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JODY L. BRIDGE,
Plaintiff
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
v.
DEBORAH W. STACKFIELD
Defendant
NO. 94-2347
CIVIL ACTION - IN CUSTODY
STIPULATION FOR CUSTODY
AND NOW come the parties to stipulate as follows:
1. Plaintiff is Jody L. Bridge, an adult individual
residing at P.O. Box 352, Boiling Springs, Cumberland County,
Pennsylvania.
2. The Defendant is Deborah W. Stackfield, an adult
individual residing at 1226 Clairmont Road, Carlisle,
Cumberland County, Pennsylvania.
3. The parties are the natural parents of two children,
Kale C. Bridge, D.O.B. 4/7/86 and Brice E. Bridge D.O.B.
9/21/87.
4. The parties agree that they shall share joint legal
custody of said children.
5. The parties further agree that the Defendant, Deborah
Stackfield, shall have primary physical custody of said
children.
SAlOIS,
SHUFF &
MAS LAND
AnDlN!YS.AT.u.W
26 W. lIIah S"...
C.,U.I., PA
6. The parties further agree that the Plaintiff, Jody L.
Bridge, shall have periods of partial physical custody as
follows:
a. On the two weekends when he has off from
work, from after school on Friday until 8:00 p.m. on Sunday;
b. During the week days of father's 10:30 p.m. to
8. The parties will alternate the following holidays: New
10:30a.m. shift, from Thursday after school until Friday
morning and during the summer months, on Fridays until mother
picks up the children following the end her work day between
4:30 and 5:00 p.m.; in addition, during the same shift, Father
shall have the children on every Monday evening from after
school until 8:00 p.m., and during the summer months for the
entire day until 8:00 p.m.
c. On the weeks of the 10:30 a.m. to 10:30 p.m.shift, from
Wednesday after school until Thursday morning, and during the
summer months, until he goes back to work on Thursdays.
d. During the weekdays when Father is on 6:30 a.m. to 2:30
p.m. shift, every Wednesday from after school until 8:30 p.m.,
from the end of Father's work day during summer vacation
months, until 8:30 p.m.
7. Each party shall also have up to five non-consecutive
weeks of physical custody in the summer. Father will notify
mother on or before May 1 of each year of his intent to use
these weeks. Further, the parties may also make arrangements
for a mid-week visit on their non-custodial work, if the
parties shall so agree.
Years Day, Memorial Day, Fourth of July, and Labor Day, and
SAIDIS,
SHUFF &
MASLAND
A1TOItNI!:YStATt1AW
26 W. Hlsh 5',..,
Cull.I., VA
each day shall begin at 8:00 a.m. and end at 8:00 p.m.,
provided that the father does not work those days. In the
event that he does work, other arrangements will be made for
half day visits. Mother shall have Memorial Day 1999 and
alternating thereafter.
. .
9. Thanksgiving shall be shared, with father having
physical custody on each Thanksgiving Day from 8:00 a.m. until
2:00 p.m., and the remaining of the holiday to mother.
10. Easter shall be shared, with father having physical
custody on each Easter Day from 8:00 a.m. until 2:00 p.m., and
the remaining of the holiday to mother.
11. The Christmas holiday shall alternate, with period
"a" being December 24 at 2:00 p.m. to December 25 at 2:00 p.m.,
and the "b" period being December 25 at 2:00 p.m. to December
26 at 2:00 p.m. Mother shall receive the first period of
physical custody in 1999, and all odd number of years, and to
alternate thereafter.
12. Each Mother's Day shall be with mother and each
Father's Day shall be with father.
13. The parties desire that this be entered as an Order of
Court and the Court shall retain jurisdiction.
\\~-(~\r L~()'~'\i(\d
Deborah w. cki~
SAlOIS.
SHUFF &
MASLAND
AlTORNEVS'AT.L\W
26 W. IIIgh S"..,
C.ull.I., Ph
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