Child Registration Form

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

Personality

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

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

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

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):

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

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

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.

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

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 REGISTRATION FORM

Demographic Information

Contact Information

Education

Disabilities