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

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
Inappropriate interactions w/strangers / Lack of awareness of others / Lying
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 specified / Mental Retardation – Genetic
Pervasive Developmental Disorder / Shaken Baby Syndrome / Other:
Current overall level of developmental disabilities: None Mild Moderate Severe

Learning Disabilities

Central Auditory Processing Disorder / Developmental Articulation Disorder / Dyslexia
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:

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

E-mail:

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:
AdoptUsKids Case #: / Heart Gallery enlargements ordered:
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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