ACKNOWLEDGEMENT OF RECEIPT OF INFORMATION

Proposed Adopted Child:

D.O.B:

Date of Placement:

Information provided to adoptive parents	Date provided	Source of Information	If not available, reasons and efforts made to obtain
Current Medical

Birth Family

Medical History

Social History

Birth parents personal statements, letter, photos, etc.

Lifebook

Other, Please specify

We acknowledge receipt of the above listed information. We have reviewed all of the information and requested that (agency name) clarify any questions regarding the material provided, or contact the source of the information for further clarification. We acknowledge that some of the information was obtained from other professionals who were involved with the child and his birth family, and thus, is subject to the thoroughness and accuracy of the source of the reported information. We accept this child based upon the background information provided which is all that is known by the (agency name) at this time.

We recognize that this child may exhibit unforeseen emotional, behavioral or physical/medical problems that might surface in the future.

We have been offered an opportunity to participate in training regarding the special needs of adopted children, especially those who have entered adoption from the foster care system.

The current law regarding searching for birthparents in this state has been explained to us.

Date:

Adoptive Parent

Adoptive Parent

(agency name) certifies the background information provided to the adoptive parents is all the nonidentifying information available to the agency about this child and is true to the best of our knowledge and information provided to us by other professionals and/or birth family members.

Adoption Caseworker:	Date:

County Caseworker:	Date:

2

Diakon / FDR – Disclosure Statement

Placement Benchmark – Benchmark Handbook – 11/02

TEMPLATE

Sue Cohick

2003-07-02

tmg

Dell Computer Corporation