D I A K O N
Lutheran Social Ministries
Our Name Means Service
99 S. Cameron St.
PO BOX 1443
Harrisburg, PA 17105-1443
1-888-793-2512
phone: 717-236-8490
fax: 717-236-8510
www.diakon-swan.org
In partnership with
Family Design
Resources
FAMILY PROFILE AUTHORIZATION AGREEMENT
I/(We) ___________________________ and ___________________________ by
(Prospective Adoptive Parent) (Prospective Adoptive Parent)
signing this agreement, acknowledge that I/(We) are aware of, and agree with the
following:
That ______________________________________ (Affiliate Agency) has provided
Me/(Us) with an orientation to special-needs adoption, to the Affiliate's policies and
procedures as they relate to special-needs adoption, and with the Pennsylvania
Statewide Adoption Network's (SWAN) policies.
That I/(We) am aware that completing the family profile and any other services
performed by the Affiliate Agency in support of an adoption through SWAN shall be
performed at no charge to Me/(Us).
That I/(We) am aware that should I/(We) desire to use my family profile to adopt a
child, other than a SWAN child, I/(We) need to purchase the profile at a cost of
$2,500.
That I/(We) am aware that the family profile will be released to another agency
conducting subsequent family profile work IF I/(WE) CHOOSE TO WORK WITH
ANOTHER AFFILIATE AGENCY.
That I/(We) am aware that the family profile will be released to county agencies (i.e.,
those agencies with custody of available SWAN children) to assist them in making a
decision regarding My/(Our) ability to meet the needs of available children.
That I/(We) are interested in adopting a SWAN child and will cooperate with the
Affiliate Agency in the completion of My/(Our) family profile.
Prospective Adoptive Parent signature Date
Prospective Adoptive Parent signature Date
Affiliate Representative signature Date