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   CHILD REGISTRATION FORM

$100 for a single child or sibling group of two (2) being registered together.

$200 for a sibling group of three (3) or more being registered together.

Your invoice will be sent directly to the contact person listed on this registration form. Scholarships may be available for children from certain areas.

CAP is a national service. In keeping with the Adoption and Safe Families Act (1997), prospective parents from across the country can inquire on this child.

Please complete each section below. Incomplete information will delay the child's registration.

NOTE: We cannot register children without a clear, high-quality photograph and a completed registration form that includes the personality thumbnail sketch. Email photos to Ilona@capbook.org

Demographic Information

Full name of child

Date of birth Gender Race
ex: 07 10 1993

Is this child being updated from a previous year?
Yes No

Legal status
Legally free Not legally free

Is the child receiving a scholarship?
Yes No I'd like more information

Contact Information

Contact person

Agency name

Mailing address

City State Zip Code

Contact person's phone

Agency phone

Agency fax

Contact's email

Education

What grade of school is the child currently attending?

Is this child in special education?
Yes No

If yes, please specify classification:

Disabilities

Does this child have a disability?

Physical Disability (please specify)

Type Severity Is therapy required?

Type Severity Is therapy required?

Type Severity Is therapy required?

Mild: Treatable medical conditions
Moderate: Conditions may require long-term therapy
Severe: Conditions that may require hospitalization or residential treatment

Emotional Disability (please specify)

Type Severity Is therapy required?

Type Severity Is therapy required?

Type Severity Is therapy required?

Mental Retardation

Severity

Please specify IQ, if known

MILD: IQ range 50-75, educable retarded, usually able to live independently, hold a job and manage their life with minimal supervision.

MODERATE: IQ range 25-50, trainable retarded, may achieve partial self-sufficiency but will always need supervision and to live in a group home or family setting.

SEVERE: IQ less than 25, profoundly retarded, may be able to partially contribute to daily activities, will be unable to work and will need ongoing supervision.

Learning Disability (please specify)

Type Severity

Type Severity

Type Severity

MILD: conditions that may require some assistance from a resource room or tutoring while attending a mainstream classroom.

MODERATE: conditions that require long term special education services.

SEVERE: conditions that cause permanent difficulty.

Siblings

Name(s) and birthdate(s) of sibling(s) to be placed with child:

(Please complete and attach a registration form for each sibling.)

Sibling #1

Sibling #2

Sibling #3

Sibling #4

Name(s) and birthdate(s) of sibling(s) who are not being registered

Sibling(s)

Personality

So that we may portray the child honestly and positively, please answer the following questions. Remember to BE ORIGINAL!

What adjectives do you think best describe the child?

What hobbies does the child participate in?

What does the child like/dislike?

What special talents does the child have?

What are the child's favorite foods? Least favorite foods?

Please explain the child's current educational status. If they are interested in higher education, please let us know what their interests include.

What is the child's favorite subject in school?

What are the child's hopes and dreams for the future?

Will the child do well in a home with other children or would they do better as an only child?

Does the child like animals? If so, what is their favorite? Do they want pets?

Does the child have siblings with whom they need to maintain contact? Are there other significant relationships that the child should maintain?

Will the child be able to function independently as an adult? If no, please explain.

What are the child's feelings about adoption? What kind of family is important to him/her?

In the space below, please provide any additional information that you feel is important or that you would like families to know about the child.

Additional Information

Check all of the following that are available (IT IS VERY IMPORTANT THAT THIS BE COMPLETED):

General subsidy Travel assistance to adoptive family

Medical subsidy Videotape of child

Payment to cooperating agency for placement and supervision

Is this child registered on the AdoptUsKids website?
Yes No
If yes, what is the case number?

Would you like CAP to register this child on the AdoptUsKids website?
Yes No

May the picture and description be used in adoptive parent newsletters, web sites, meetings, conferences, newspaper and magazine articles and on posters and fliers?
Yes No

Are there geographical restrictions for this child's placement?
Yes No

A clear, high-quality photograph which portrays the child positively is important. Digital photographs should be in jpg format and have a resolution of at least 300dpi. Please email your photograph directly to Ilona@capbook.org, indicating who the child is in the email subject.

We can also work with original hardcopy photographs. Please mail these to: CAP Registration, 595 Blossom Road, Suite 306, Rochester, NY 14610. If you would like information about free SEARS photographs please contact us toll-free at 1.888.835.8802.

Agreement for Registering Children

Children Awaiting Parents, Inc. is offering recruitment services by featuring the registered child in The CAP Book, on The CAP Book web site and AdoptUSKids web site. In addition, extra recruitment will be provided for the child in the forms of recommending the child to be featured in The Heart Gallery, videos, parent group publications, adoption.com websites, meetings/conferences, various magazine and newspaper articles, on posters and fliers to be distributed nationally, on CAP's Friday's Child segment and through our Faith in Children initiative.
To receive all recruitment services mentioned above, please read the agreement and sign below:
Children Awaiting Parents, Inc. will:

Promptly photo list the child in The CAP Book and on The CAP Book web site and AdoptUSKids web site.

Provide extra recruitment for the child by recommending him/her to be featured in the Heart Gallery, videos, parent group newsletters, adoption.com websites, meetings/conferences, various magazine and newspaper articles, on posters and fliers to be distributed nationally, CAP's Friday's Child segment and through our Faith in Children initiative.

Insure that authorized information about the child will be presented in an accurate and sensitive manner.

Take all inquiries on the child and refer homestudied families and adoption agencies to the child's agency contact.

Keep the child's agency contact appraised of recruitment efforts and responses.

Maintain contact with the child's agency contact to insure that accurate and updated information is available.

Advocate for the child.

On behalf of the agency for which I work, I certify that it and I have legal authority to register the child listed and authorize the publication of him/her, and grant you authority to copy and disseminate the photograph provided. I hereby authorize and request that the child listed be registered and publicized as indicated above. I certify that the information provided about the child is accurate and complete. I understand that Children Awaiting Parents, Inc. is not a placing agency. The agency I represent retains complete authority and agrees to indemnify and hold harmless Gannett Co., Inc. and all other media owned by Gannett Co., Inc., including the Rochester Democrat & Chronicle, Inc., its agents, employees and independent contractors from any liability in connection with the registration and publicity of this child, consistent with this agreement. This also agrees to indemnify and hold harmless Children Awaiting Parents, Inc., its agents, employees and independent contractors from any liability in connection with the registration and publicity of this child, consistent with this agreement.

Child's full name

Custodial agency of child

Authorized signature

Title

Date