Child Information. Child’s First Name: Child’s Date of Birth: Date Child Freed for Adoption: Date Adoptive Placement Agreement Signed: Date of Disruption from Previous Adoptive Placement (If Any): Date Child Entered Adoptive Home: Full Name and Address of Adoptive Parent(s) Adoptive Parent: Adoptive Parent: Address: City: County: State: Zip: Phone: ( ) Ext: Name and Address of Social Services District or Voluntary Authorized Agency with custody and guardianship of child Name: Address: City: County: State: Zip: Case Manager’s Name: Case Manager’s Phone Number: ( ) Ext. Name and Address of Agency of Case Planner (If Applicable) Name: Address City: County: State: Zip: Case Planner’s Name: Case Planner’s Phone Number: ( ) Ext. Section II Purpose of the Agreement Both federal and State law require that payments for an adoption subsidy and non-recurring adoption expenses must be made in accordance with a written agreement. This Agreement will enable the social services district worker and/or the agency worker to determine whether an adoption subsidy and non-recurring adoption expenses will be provided. New York’s Adoption Subsidy and Non-Recurring Adoption Expenses Programs provide subsidy payments to all parents adopting eligible children without regard to the adoptive parent(s) income. However, there are a number of factors that determine the extent and type of benefits that will be provided. These are explained in the Summary of New York’s Adoption Subsidy and Non-Recurring Adoption Expenses Programs that is attached to this Agreement and is incorporated herein (see Appendix A). This Agreement will clearly spell out the benefits to be provided, and identify the provisions affecting those benefits. It will also specify the circumstances under which the benefits may be changed in the future and whether such changes require a new Agreement and State approval or only an amendment to this Agreement. New York State law provides that an application for an adoption subsidy may be accepted before the child is completely freed for adoption, but final approval of the application may not be granted until the child is completely freed for adoption.
Child Information. The following identifying information is provided concerning the child:
Child Information. 3.8.1 Parent(s) must acknowledge in writing receipt of all child information documents provided through MLJ Adoptions. Parent(s) must accept or reject the referral within a reasonable time after the proposed referral is made. Any rejection of a referred child deemed “unreasonable” by MLJ Adoptions or governmental or non-governmental organization in the Child’s country of origin may result in no additional referrals. In this event, the Agreement will terminate automatically.
Child Information. 1.7.1 MLJ Adoptions receives information about the Child that is under consideration for adoption from the sending country. Depending on the country, MLJ Adoptions international supervised provider or the country’s Central Authority or its designee will initially identify a child for adoption and provide the child’s background study. MLJ Adoptions' international supervised provider or the country’s Central Authority or its designee, will secure the necessary consent or termination of parental rights to adoption. MLJ Adoptions shall make reasonable efforts to obtain all available medical, psychological, and historical records regarding the referred child. MLJ Adoptions shall provide Parent(s) with copies of the referred child’s medical, developmental, and social records to the extent such records are available to MLJ Adoptions. Nothing in this agreement shall be construed to create an obligation on the part of MLJ Adoptions to conduct any assessment, evaluation, testing, or screening of any child.
Child Information. Child’s First Name: Child’s Date of Birth: Date Child Freed for Adoption: Date Adoptive Placement Agreement Signed: Date of Disruption from Previous Adoption Placement (If Any): Date Child Entered Adoptive Home: Date Adoption was Finalized (Application Following Finalization): Full Name And Address of Adoptive Parent(s): Adoptive Parent: Adoptive Parent: Address: City: County: State: Zip: Phone: ( ) - Ext: Name and Address of Social Services District or Voluntary Authorized Agency with custody and guardianship Name: Address: City: County: State: Zip: Case Manager’s Name: Care Manager’s Phone Number: ( ) - Ext. Name and Address of Agency of Case Planner (If Applicable) Name: Address: City: County: State: Zip: Case Planner’s Name: Case Planner’s Phone Number: ( ) Ext.
Child Information. The purpose of this page is to determine how much of the family’s program costs will be covered by the scholarship. Enter information about the family’s schedule, rate (tuition amount based on the rate unit type), CCAP payments (payments from CCAP, not the family’s co-pay), and fees. Use this information to calculate the charge to scholarship and the remaining family charge. Use attached Family Payment Worksheet to help you with your calculations Charge to Scholarship: The “Charge to Scholarship” is the total amount to be paid out of the child’s scholarship for the full period of enrollment within the dates of the child’s scholarship award. Contact the Area Administrator if you are unsure how much time is left in a child’s award.
Child Information. Parent(s) travel for the purposes of adoption. Parent(s) further understand that this does not signify any fault or negligence of MLJ.
Child Information. List your child’s hobbies or interest List any foods your child likes or dislikes Xxxxx’s sleeping habits: Likes to be rocked Special to in bed Thumb sucking Special blanket Night light Other Does your child enjoy playing with other children or do they prefer playing alone? How does your child react in new situations? Does your child seem reluctant to be left in the care of others? Does your child express fear of: People Darkness Dogs Loud Noises Other What methods of discipline work best with your child? Does your child have angry outburst, temper tantrums, or sullen spells? If yes, how do you handle these situations? Please describe any concerns or expectations regarding your child’s preschool/kindergarten education: Is there any other information you would like to share with your child’s teacher that may be helpful? Parent/Guardian’s Name Date Climbing Tree Community School, an Early Learning Center 1695 N Country Club Rd. Tucson, AZ 85716 ⬩ 000-000-0000 ⬩ xxx.xxxxxxxxxxxxxxxxxx.xxx ⬩ xxxx@xxxxxxxxxxxxxxxxxx.xxx Child Development Information Child’s Name First Middle Last Has your child had previous experience in preschool or daycare? Please give the age (exact or approximate) at which the following tasks were accomplished Rolled over both ways Sat up alone Crawled Stood up alone Walked Talked Toilet Training: Started Completed Has your child had the chicken pox: Yes No Does your child have any of the following: Frequent colds Constipation Hay fever Heart Trouble Frequent earaches Severe allergies Diarrhea Nose bleeds Stomach upsets Diabetes Nightmares Asthma Prolonged fevers Other Medical Conditions If yes to any of the above, please explain frequency and circumstance: Do you feel has behavioral or emotional difficulties? Has your child see a specialist for this issue? Name of specialist or physician Does your child have any speech or language difficulties? Has your child see a specialist for this issue? Name of specialist or physician Does your child have any hearing difficulties: Has your child see a specialist for this issue? Name of specialist or physician Is there any other information your child’s teacher may find helpful to know about your child’s development? Parent/Guardian Name Date Climbing Tree Community School, an Early Learning Center 1695 N Country Club Rd. Tucson, AZ 85716 ⬩ 000-000-0000 ⬩ xxx.xxxxxxxxxxxxxxxxxx.xxx ⬩ xxxx@xxxxxxxxxxxxxxxxxx.xxx Family Agreement and Understanding Child’s First and Last Name Parent First and Last Name Da...
Child Information. Child first name Child middle name Child last name Child name: unknown Date of birth: month, day, and year Date of birth: unknown Date of death: month and day Date of death: unknown Residential address: unknown Residential address: street Residential address: apartment Residential address: city Residential address: county Residential address: zip County of death
Child Information. I understand that it is my responsibility to inform the Center of any changes to the information on the Emergency Information Form, including but not limited to address, home and work phone numbers, and pick-up authorization and medical conditions.
