SWAN Adoption Placement Agreement

I/We, the undersigned, do fully understand and agree to accept the following regulations of the (agency name) under contract with the Statewide Adoption Network to provide adoption services to children in need of services as defined by the SWAN program policies. I/We acknowledge that prior to deciding to accept placement of this child we have been provided an opportunity to review all the information known by (agency name) on the child's social and medical history and have made a decision to accept placement of this child based upon the information previously provided. (See attached document titled Acknowledgment of Receipt of Information) In consideration thereof I/We agree to cooperate with the following terms:

To accept placement of the child for a supervisory period during which time regular support services are provided to the family to assist in achieving a successful adjustment.

Pre-adoption supervision shall consist of a minimum of one visit per month for a minimum of six months. Reports on the family's adjustment to the child and the child's adjustment to the family and school as well as his or her understanding of the adoption, response to any treatment and an assessment of his or her development will be sent to the county with custody

.

To assume full responsibility for food, clothing and medical care of the child. The county agency with custody of the child shall certify the child's eligibility for adoption assistance and, in consultation with the adoptive parent, shall determine the terms of the adoption assistance agreement. The adoption assistance agreement is separate from this placement agreement and (agency name) cannot determine the conditions of the subsidy agreement.

To comply with required safety regulations, as discussed during the home study and pre-placement visits based upon the age of the child and/or specialized developmental or health needs of the child and in accordance with Pennsylvania state law governing such things as transporting children in automobiles.

To notify the Agency at once of any changes in our household. We agree not to make any private or other agency arrangements for boarding or adopting other children without approval from (agency name).

To notify the Agency promptly of any change of address. If we plan to move our residence to another area where it would be unreasonable for (agency name) to continue to provide pre-adoption services, necessary arrangements will be made for another SWAN agency to provide the services.

To obtain advance permission from the Agency to take the child beyond the State boundaries for vacations, etc.

To give at least fourteen (14) days notice to the Agency for the removal of the child, if a major problem develops in our family.

To recognize the right of (agency name) in consultation with the county child custody agency to remove the child from our home when the child's safety is at risk or when basic developmental needs are not being met.

The supervisory period may be extended beyond the minimum required six months. The decision for an extension of said period will be reached at the request of the adoptive family, and/or at the recommendation of (agency name) in consultation with county child custody agency.

To institute proceedings for the legal adoption only after permission has been received from the agency with child custody. The decision to consent to the adoption will be based on the content in the pre-adoption supervisory reports provided to the county agency by (agency name) and in discussion with involved parties.

(agency name) will cooperate with the attorney selected by the adoptive parents to represent them in legal adoption proceedings. We encourage you to select an attorney familiar with agency adoption. (agency name) will provide a written report to the court where finalization will occur regarding the appropriateness of finalizing the adoption. Such report cannot be prepared without certain documents being supplied to the Agency by the adoptive family (medical health statements, psychological waivers on the child if applicable, and up-dated child abuse and criminal clearances depending upon when the clearances were obtained at the time of home study evaluation).

Prior to finalizing the adoption, (agency name) will make a determination if post-adoption services would further support the success of the adoption placement. If the family agrees to accept such services, a plan will be developed to provide services after adoption finalization to support continued family and child adjustment.

To accept changes in this agreement pending any new policies or procedures issued for us to implement by the SWAN management contractor or Dept. of Public Welfare.

ADOPTIVE NAME OF CHILD	BIRTHDATE	DATE OF PLACEMENT

ADOPTIVE PARENT	DATE

ADOPTIVE PARENT	DATE

AFFILIATE CASEWORKER	DATE

AFFILIATE SUPERVISOR	DATE

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Diakon / FDR – Placement Agreement

Placement Benchmark – Benchmark Handbook – 11/02

Elisa Esh

2003-07-02

tmg

Diakon