Waiting Child Enrollment Form

Waiting Child Enrollment Form Please type information in gray boxes. Use “Tab” button to move through the form. This form will be used to list the child on fouroaksfamilyconnections.org and to register the child on AdoptUsKids.org.

Today’s Date: Child Detail First Name: Middle Name: Last Name: Preferred Name: Birth Date: Gender: Male Female Race: (check all that apply) African American/Black White/Caucasian Hispanic/Latino American Indian/Alaskan Native Asian Pacific Islander/Native Hawaiian Other: FACS Exchange #: C00 Legally free: Yes No TPR date: Date of Last Removal: Does ICWA Apply: Yes No County Jurisdiction: Is child part of a sibling group? Yes No If yes, will child be adopted with siblings? Yes No If yes, list siblings: Current placement: Foster home Relative PMIC Residential treatment Youth shelter Other: Is there a current caretaker who could provide additional information about the child? Yes No Name: Relationship to child: Phone: Email: # of years in care: # of adoption disruptions: # of placements: Are there significant relationships the child needs to maintain? Yes No If yes, with whom? Is it necessary that the child’s adoptive family reside in Iowa? Yes No If yes, why? If no, which other states would you consider? All states Iowa and bordering states The following states: Is child allergic to smoke? Yes No Allergic to pets? Cats Dogs Other: Please list any additional allergies (food, medicine, etc.): Adoption Assistance Eligibility: Ongoing Financial Assistance Ongoing Medical Assistance Ongoing Mental Health Assistance Non-recurring adoption costs Other:

Worker Detail DHS Worker: DHS County Office: Street Address: City: Zip: Phone #: Fax #: E-mail: Contact preferences or notes:

Photo Detail Studio Name: Studio Phone # : City: Photographer: Appointment date: Time: Notes: I need contact information for a photographer near (city, county): Recruitment Authorization

1 of 4 Please give permission for promoting this child in the following ways: Newspaper: Yes No Newsletter: Yes No Social Media: Yes No May this child be registered on the AdoptUsKids website? Yes No If no, please list reason: Date: Name of authorizer: If no, please complete form 470-4155, AdoptUsKids Waiver. May this child be interviewed and featured in an Iowa’s Child television special? Yes No May this child’s enlarged portrait be featured in the Heart Gallery of Iowa? Yes No If yes, are there any locations (counties, cities, etc.) to avoid?

Type of Family Family Type: (Preference for family composition, check all that apply) No Preference 2 Parents 1 Female Parent 1 Male Parent Other Children: No Preference Must have other children No other children Must be youngest Must be oldest Female siblings only Male siblings only Religious Preference: Yes No If yes, which religion?

Risk Factors Alcohol exposed in utero Drug exposed in utero Failure to thrive History of abuse or neglect History of multiple placements Mental illness in birth family Mental retardation in family Premature birth Schizophrenia in birth family Sexual abuse Other:

Physical/Medical Disabilities Allergies Asthma ADD ADHD Blindness Cerebral Palsy Cystic Fibrosis Deaf Encopresis Enuresis Fetal Alcohol Syndrome Hearing loss – partial Heart Defect Hydrocephalus Microcephaly Muscular Dystrophy Respiratory problems Seizure disorder Sickle Cell Anemia Sickle Cell Trait Speech Disorder Tourette Syndrome Visually impaired Other: Current overall level of physical/medical disabilities: None Mild Moderate Severe

Emotional Disabilities Adjustment Disorder Attachment Disorder Depression Bipolar Disorder Conduct Disorder Loss Issues Generalized Anxiety Disorder Hyperactivity Post Traumatic Stress Disorder Obsessive Compulsive Disorder Oppositional Defiant Disorder Schizophrenia Psychosis Reactive Attachment Disorder Other: Separation Anxiety Disorder Takes psychiatric meds Current overall level of emotional disabilities: None Mild Moderate Severe Cruelty to animals Damages property Displays oppositional behavior Fire setting History of playing w/matches Hyperactive

2 of 4 Inappropriate interactions Lack of awareness of others Lying w/strangers Masturbates in public Physically acts out towards adults Physically acts out towards peers Runs away Sexually acts out with peers Sexually provocative behavior Stealing Unable to sustain attention Other: Current overall level of behavioral disabilities: None Mild Moderate Severe Behavioral Disabilities

Developmental Disabilities Asperger’s Syndrome Autism Down Syndrome Drug Exposed in utero Mental Retardation – cause not Mental Retardation – Genetic specified Pervasive Developmental Shaken Baby Syndrome Other: Disorder Current overall level of developmental disabilities: None Mild Moderate Severe

Learning Disabilities Central Auditory Processing Developmental Articulation Dyslexia Disorder Disorder Expressive Language Disorder Motor Skills Disorder Non-Specific Learning Disorder Receptive Language Disability Other: Current overall level of learning disabilities: None Mild Moderate Severe

Biographical Information This child enjoys (hobbies, sports, animals, church, outdoors, etc.):

Describe this child’s personality:

This child excels at:

This child requires help with:

Describe how this child is doing in school:

What positive comments do you or others have about this child (foster parent, teacher, social worker)?

Describe characteristics that the adoptive family should have:

What type of family does this child want?

What activities would this child like to do with their adoptive family?

What is the most important thing this child wants people to know about them?

Additional information to share about this child:

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Send completed form via e-mail (preferred), mail, or fax to:

E-mail: [email protected]

Mail: Four Oaks Attn: Photolisting 2100 1st Ave NE Cedar Rapids, IA 52402

Fax: 866-947-2300

www.fouroaksfamilyconnections.com

For Four Oaks use only: Date form received: Date photos received:

Date posted on Four Oaks site: Photo notes:

Date registered on AdoptUsKids: Heart Gallery enlargements ordered: AdoptUsKids Case #: Date received: Child featured in:

Date removed from site: Reason:

Date reposted on Four Oaks site: Reason:

Final removal date: Reason:

Update Information:

Rev. 07/2017

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