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JIS CODE: AGM

STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION

CASE NO. ANNUAL REPORT OF JUVENILE GUARDIAN ON CONDITION OF CHILD
Court telephone no.

COUNTY
Court address

This report should be completed annually by the juvenile guardian, or more often if directed by the court. 1. In the matter of
name, alias(es), DOB

2. I,

Name (type or print)

, am the juvenile guardian of the child named above and my to
Date Date

annual report for the period 3. Living Arrangement a. Current address and telephone number of the child: b. The child has been in the present residence since Date the changes and the reasons for change:

is as follows:

. If moved within the past year, state

4. Physical Health good. fair. poor. The child's current physical condition is excellent. During the past year the child received the following medical treatment, including check-ups and optical and dental work.
(Specify each date, ailment, type of treatment, and doctor's name.)

5. Mental Health The child's current mental condition is excellent. good. During the past year the child received the following mental health services.
(Specify any prescribed medications, treatment received, and doctor's name.)

fair.

poor.

(CONTINUED ON OTHER SIDE)

Do not write below this line - For court use only

JC 94 (6/09)

ANNUAL REPORT OF JUVENILE GUARDIAN ON CONDITION OF CHILD

MCL 700.5215(f), MCR 3.979(E)(1)

6. Education State whether the child regularly attends school, where the child attends school, and what grade the child attends. If the child attends alternative education, state where and the grade. If the child does not attend school, explain why.

7. Activities Describe the child's involvement in social, religious, and sports activities.

.

8. Parenting Time Describe any parenting time between the child and his/her parents. Provide the address for each parent. Describe anything about the parenting time you believe is important for the court to know.

9. Other State any information about the child that you believe is important for the court to know, such as special awards or recognition the child has received, any special needs the child may have not otherwise stated above, any contact with law enforcement or child protective services, etc.

Date Signature of juvenile guardian Address City, state, zip Telephone no.