Massachusetts Adoption Resource Exchange Home Page

CHILD REGISTRATION FORM

Please fill in all blanks and check all boxes that apply. Once this form is received, MARE will begin the matching process for this child. However, the child cannot be featured in the MARE Photolisting® and other media recruitment until clear photos of child are received by MARE.Click here to download the Child Registration Form for you to print, complete and fax to MARE at
617-542-1006.

CHILD INFORMATION

First Name:
Last Name:
Alias:	(only for children who are legal risk)
Nickname:
Date of Birth:	(mm/dd/yy)
Gender:	Male Female
Legal Status:	Free Legal Risk
Year Child Entered Care:
Is child to be adopted as part of a sibling group?: Yes No
If yes, indicate total number of children in group:
Does child need contact with other siblings?: Yes No
If yes, please describe (i.e. brother, sister, monthly, etc.):
Does child need contact with other birth family?: Yes No
If yes, please describe:
Ethnicity: (Please check all that apply)	African American Asian Caucasian Hispanic/Latino Native American If other, please specify:
Primary Language Spoken:
Other Language(s) Spoken:
AREAS OF SPECIAL NEEDS:
Physical:	Type:
Emotional:	Therapy: Yes No
Intellectual:	Type:

RECOMMENDED FAMILY CONSTELLATION (Please check all that apply)
	Two parents Single parent (female) Single parent (male)	With children With no children With older child(ren) With younger child(ren)
If you are only considering two-parent families, please give clinically appropriate reason:
Other considerations for placement:
Please indicate areas to be avoided in recruitment:

WORKER INFORMATION

Recruitment Worker:

Agency:

Mailing Address:

(Apt., Suite or Floor)

(City) (State) (Zip)

Phone #:

Fax #:

Email:

Adoption Worker:

Agency:

Mailing Address:

(Apt., Suite or Floor)

(City) (State) (Zip)

Phone #:

Fax #:

Email:

This form is not intended to provide a complete or clinically oriented discussion of children. Because it is important to present a child in a perspective most relevant to a parent, adoption/recruitment workers are encouraged to seek current information from the child’s caretakers in order to successfully complete this form.

PERSONALITY (How does child describe him/herself? How do others describe child’s character?)

INTERESTS: (Describe what child enjoys doing.)

TALENTS: (Describe unique aspects of child in terms of what he/she does best.)

ASPIRATIONS: (Describe what child wants to be in the future –career or educational goals.)

FAMILY LIFE: (Describe child’s interaction and behavior in a family or residential setting.)

SCHOOL LIFE: (Describe child’s academic functioning, grade level, school behavior, peer relationship.)

SPECIAL NEEDS: (Briefly describe child’s disabilities, behavioral difficulties, therapy, medication.)

PLACEMENT REQUIREMENTS: (Include what child wants in a family and worker’s recommendations.)

IF THIS CHILD COULD HAVE ONE WISH, WHAT WOULD IT BE?:

IMPORTANT: Once this form is received, MARE will begin the matching process for this child. In order to include the child in the MARE Photolisting®, you must include a close up photo of the child, ideally one in which his/her face is at least 2 inches high. For siblings, please send a group photo along with the individual photographs of the children. You can send photos to MARE via email in .jpg format with the child's full name. If you have a problem getting good quality photographs, please call MARE for assistance.

Form completed by: