Child Entry Form for Child Appearing in MARE Book (for recruitment purposes)
(NOTE: All fields in RED must be complete, or form will not be accepted)
CHILD INFORMATION
Child's Last Name: Child's First Name: (only child's first name will be used)
Permanent Custody Date: (mm/dd/yy) Date of Birth: (mm/dd/yy) Gender: Male Female
DHS Case No.: County of Commitment: (Select one) Alcona Alger Allegan Alpena Antrim Arenac Baraga Barry Bay Benzie Berrien Branch Calhoun Cass Charlevoix Cheboygan Chippewa Clare Clinton Crawford Delta Dickinson Eaton Emmet Genesee Gladwin Gogebic Grand Traverse Gratiot Hillsdale Houghton Huron Ingham Ionia Iosco Iron Isabella Jackson Kalamazoo Kalkaska Kent Keweenaw Lake Lapeer Leelanau Lenawee Livingston Luce Mackinac Macomb Manistee Marquette Mason Mecosta Menominee Midland Missaukee Monroe Montcalm Montmorency Muskegon Newaygo Oakland Oceana Ogemaw Ontonagon Osceola Oscoda Otsego Ottawa Presque Isle Roscommon Saginaw Sanilac Schoolcraft Shiawassee St. Clair St. Joseph Tuscola Van Buren Washtenaw Wayne Wexford
Race/Ethnicity: (Select one) African American African American/Caucasian Asian Caucasian Hispanic Hispanic/Caucasian Native American Native American/Caucasian Other Religious Preference:
Is child being adopted as part of a sibling group? Yes No Names of siblings being placed together:
CHILD'S PERSONALITY
Describe POSITIVE characteristics of this child, including strengths, likes, interests and special talents:
Describe any dislikes, limits, or behavioral concerns that child may display in a family setting:
EDUCATION LEVEL
Grade: (Please select one) Not in school Ungraded Preschool Kindergarten 1st grade 2nd grade 3rd grade 4th grade 5th grade 6th grade 7th grade 8th grade 9th grade 10th grade 11th grade 12th grade Certified Special Education: LD - Learning Disabled EI - Emotionally Impaired EMI - Educably Mentally Impaired SMI - Severely Mentally Impaired TMI - Trainably Mentally Impaired SXI - Severely Multiply Impaired Other
Learning Disability Level: None Mild Moderate Severe Diagnosis and/or example of disability:
Describe the child's academic functioning, behavior in the classroom, and peer relations.
CHILD'S HEALTH AND DEVELOPMENTAL STATUS
Describe how their impairments are demonstrated in daily functioning.
Please list specific diagnosis (if any) and explain how this is demonstrated in daily functioning:
QUALITIES / SKILLS OF ADOPTIVE FAMILY:
Briefly describe the qualities that would be important for a potential adoptive family to demonstrate in order to approprately address this particular child's needs:
*** MARE strongly suggests that workers also provide the purple "What I Want Others to Know About Me" form to the child to fill out and the gold "What others say…" form to foster parents, therapists, etc. to fill out to provide additional information that will help MARE provide a more well-rounded description of the chiold.
ADDITIONAL INFORMATION
Will child function independently as an adult? Yes No May need assistance
Legal Status: (Select one) Legally free Legal risk (appeal pending)
Video of child available? Yes No Would you like MARE to vidoetape the child for recruitment purposes? Yes No
Child's photo may be used for: (Select one) Any recruitment opportunities Posters Newspaper Columns Posters and Newspaper
Can child be considered for out-of-state adoption? Yes No If no, why?
Are foster parents or relatives interested in adopting the child? No Yes
Is there an interested family at this time? No Yes
If yes, please explain reason for photolisting:
AGENCY INFORMATION
Agency Responsible for MARE registration:
Contact worker for inquiries:
Contact worker's phone number and extension:
Contact worker's agency (if different from above):
Your email address:
Agency address (street, city, state, zip):
How will MARE be receiving the child's photo? (Select one) Email Regular Mail When can MARE expect to receive the photo?
PLEASE NOTE: A clear, well-lighted photo of the child or sibling group must be submitted along with this registration form.
You may email a photo
You may also mail a photo of the child or sibling group to the MARE office.
MARE also offers photo coupons for Walmart portrait studios to be used for children listed on MARE. Please phone MARE for more information.
Photos that are sent by fax, photocopies or scanned and printed on paper will not be accepted. Photos and digital images that are dark and/or blurry will not be accepted.
If no photo is submitted by mail or email, the registration form will be returned to the worker and may be counted as late if re-submitted to MARE after the original due date.