If yes, who? self parent grandparent If yes, who? self parent grandparent With what tribe? With what tribe? Single Single Married Marriage Date(s) & Place: Married Marriage Date(s) & Place: Spouse Name: Birth Parents Application of Services Birth Parents' Information Date of application: Birth mother name (please print) Birth father name (please print) Birth mother's race Birth father's race Native American heritage? Yes / No Registered? Yes / No Native American heritage? Yes / No Registered? Yes / No Spouse Name: Divorced Divorce Date(s): Divorced Divorce Date(s): Separated Separation Date: Separated Separation Date: Current Living Arrangements? Deceased Death Certificate Date: Please provide all applicable documents such as marriage license, divorce/separation decrees, and/or death certificate. Have you ever been diagnosed with sickle cell anemia or sc anemia trait? Yes / No Birth father? Yes / No Please specify Please describe your relationship with the birth father including any concerns you have: If the birth father is unknown, what are the circumstances of the pregnancy? Does he know you are pregnant? Yes / No Does he know you are considering adoption? Has he helped you financially? Yes / No How much? Yes / No Does he agree the child is his? Yes / No Is he willing to consent to adoption? Yes / No Has he supported you any other way? Yes / No If yes, please explain: Commitment to Adoption On a scale of 1 to 10 with 10 being most committed, how sure are you about placing your child for adoption? Why? Who is aware of and supportive of your decision to place your child for adoption? Have you ever placed a child for adoption before? Yes / No If yes, when and where? How did you hear about A Guardian Angel Adoptions? (Mark all that apply) Yellow Pages Internet Facebook Twitter Google Referal (who) Pregnancy Information Due date of baby: Sex of child: Male Female Unknown First day of last period: Do you know where you want to deliver? If yes, city and state? Hospital and doctor? Willing to travel to Utah to deliver baby? Yes / No If yes, when would you plan to arrive in Utah? Have you ever been pregnant before? Have you ever had a miscarriage? Have you started prenatal care? Date of last visit: Results: Have you had an ultrasound or sonogram? When? Where? Results: Current doctor Have you discussed adoption with a doctor? Will you continue to see this doctor? Office phone Location:
Birth mother's full name Date of birth Street address Birth Mother Personal Information First Middle Last Maiden (if applicable) Age Place of birth US citizen Yes / No if no, citizen of what country? City State Zip Home phone Cell phone Other phone Social security number Driver's license number (if applicable) State issued Height: Weight: Hair color: Eye color: Physical build (big/small boned, muscular, etc.): Complexion (circle one): fair, medium, olive, dark Unique features (freckles, moles, etc.): Which of the following describes your personality? (circle all that apply) Aggressive Calm Friendly Fun Irresponsible Nervous Critical Emotional Other: Name: Address: Happy Helpful Outgoing Open-minded Emergency Contact Information: Relationship: Phone number: Rebellious Selfish Self-Confident Serious Shy Stubborn Temperamental Unhappy Friend or relative who would be able to contact you in the future: Name: Relationship: Address: Phone number: Presently in school? College/Vocational training? If yes, describe: Current occupation Birth Mother Education and Employment Information Last grade completed? Average grades received? Diploma or GED? Military service? If yes, what branch? Work address and phone number Other Children Information Age & Birth How Any physical/ Living Name Sex birth date weight/length delivered? mental problems? with you? If no, where? Do you have medical insurance? Pregnancy Related Expenses Yes / No Name of company? Work or personal? Do you receive financial assistance from any source? How much money do you need a month to cover expenses? $ Yes / No Source? Describe expenses: Amount per month?
Drug History Please fill out the following drug history to the best of your knowledge. In the space "when used" please state if you used the drugs "before conception" or "during pregnancy" or, both if applicable. Name How much How often When used Name How much How often When used Prescription Cocaine Over-the-counter (pain/cold/allergy medicines) Alcohol Amphetamine Barbiturate Cigarettes Heroin LSD Marijuana Meth Other Other Mental Illness History Please indicate if you, the birth father, or anyone in either family has any of the following: Depression Yes / No Bipolar Yes / No Schizophrenia Yes / No Panic Attack Yes / No Who: Who: Who: Who: Please list any physical illnesses or mental illnesses you or the birth father might have: Birth mother: Birth father: Birth father's full name Birth Father Personal Information First Middle Last Unknown Date of birth Street address Age Race US citizen Yes No if no, citizen of what country? City State Zip Phone Height: Weight: Physical build (big/small boned, muscular, etc.): Hair color: Complexion (circle one): fair, medium, olive, dark Eye color: Unique features (freckles, moles, etc.): Which of the following describes the birth father's personality? (circle all that apply) Aggressive Friendly Irresponsible Rebellious Shy Calm Fun Nervous Selfish Stubborn Critical Happy Outgoing Self-Confident Temperamental Emotional Helpful Open-minded Serious Unhappy Other: Birth Father Education and Employment Information Presently in school? Last grade completed? Average grades received? Diploma or GED? College/Vocational training? If yes, describe: Military service? If yes, what branch? Current occupation Work address and phone number Adoptive Family Information Would you like to choose your adoptive family? Yes / No Would you like to talk with your adoptive family? Yes / No Would you like to meet your adoptive family? Yes / No What contact do you want from the family after the baby is born? (circle all that apply) Pictures: Regularly Occasionally Never Letters: Regularly Occasionally Never Other:
Values and Characteristics of Adoptive Family Please be aware A Guardian Angel Adoptions, LLC cannot guarantee that your adoptive family will meet all your preferences. We do not discriminate against families based on marital status, sex, or religion. Please discuss any preferences you feel especially strong about before you decide to use our services. (Please circle all that apply) Marriage: Two parent Single Does not matter Other Age: Young Middle-aged Does not matter Other Race: Same as baby Caucasian Does not matter Other Children: None One or two Does not matter Other Education: Important Moderate Does not matter Other Financial: Wealthy Secure Does not matter Other Religion: Christian Non-Christian Does not matter Other Please describe your ideal adoptive family: What is the most important characteristic you want in an adoptive family? Please list any other concerns or questions you may have. I certify to the best of my knowledge that the information provided here is true and correct and I am signing this of my own free will. Signatures Birth mother name Date Birth mother signature Birth father name Date Birth father signature
Statements of Understanding Purpose The purpose of this form is for the birth mother to understand all her rights and the rights of A Guardian Angels Adoptions, LLC through the adoption process. Please initial each statement, only after you have thoroughly read each statement. Statements Right to Parent: Birth Father Rights: Application for Services: Fraud Statement: Policies and Procedures: Alcohol and Drug Use: Drug/HIV Testing: Statements Purpose or Explanation As the birth parent of my child, I have the primary right to parent my child if I so choose, even if I am a minor. I will make sure that it is my wish to place my child for adoption before I begin working with A Guardian Angel Adoptions, LLC. I understand that according to the adoption laws of the state of Utah that the birth father may have the option of parenting the child if he is known and paternity has been established. In order to establish paternity in Utah, he must support me emotionally and financially during my pregnancy or he must file with Utah Vital Records on the State Paternity Registry. Paternity laws of the father s state of residence must also be complied with. Furthermore, I understand that if a birth father resides in another state and I am withholding information about my whereabouts, I may be putting my adoption placement in jeopardy. Also, if I am married, my legal husband must consent to an adoption even if he is not the child s biological father. Notice must also be given to any birth father I may identify on the birth certificate. I, at my own discretion, have decided to apply with A Guardian Angel Adoptions, LLC for assistance with my adoption plans. All information I have supplied throughout the application process is true and correct to the best of my knowledge. I understand that misrepresenting my pregnancy or my desire to place for adoption is considered fraud. I also understand that receiving assistance and support from more than one adoption agency at the same time may also be considered fraud. A Guardian Angel Adoptions, LLC may choose to prosecute me if I have committed a fraudulent act. I also understand that adoption agencies may share information about me with other agencies in an effort to prevent fraud. I understand that there are Policies & Procedures of A Guardian Angel Adoptions, LLC that I must follow. If I decide not to follow these policies I understand that A Guardian Angel Adoptions, LLC has the right and responsibility to discontinue their services. Before accepting any services from A Guardian Angel Adoptions, LLC, I agree to follow those Policies and Procedures. I understand the use of alcohol or illegal drugs during my time as a client with A Guardian Angel Adoptions, LLC is prohibited. If I am using drugs or alcohol while I am a client through this agency, they have the option of terminating services and/or referring me to a drug or alcohol treatment facility as well as to the appropriate law enforcement. I understand that A Guardian Angel Adoptions, LLC will request that I participate in drug and HIV testing. These tests are done automatically for all birth parents working with A Guardian Angel Adoptions, LLC. Initial here Jurisdiction: If I chose to travel to Utah, I expressly submit to the jurisdiction of the courts of the state of Utah and agree to be bound by laws of Utah. A Guardian Angel Adoptions, LLC P.O. Box 95902, South Jordan, UT 84095 Statements of Understanding 5
Choice to Travel: Statement of Liability: Living Expenses: Living Arrangements: Release of Information: Counseling: Permission: Other Services: Privacy Statement: Selection and Information Sharing: I understand that A Guardian Angel Adoptions, LLC neither encourages nor recommends longdistance travel by any means within two weeks of my due date. If I choose to travel to Utah, I take full responsibility for my decision to travel and for any consequences resulting from the trip, be they physical, financial, emotional, or otherwise, for myself and for any of my children traveling with me. I willingly and knowingly choose to leave, the state in which I have been residing, and release A Guardian Angel Adoptions, LLC from responsibility for the choice to travel. I acknowledge that A Guardian Angel Adoptions, LLC is providing services to me in good faith and I do not hold them responsible or liable in any way for any harm or accident that may come to me during my association with them. I understand that A Guardian Angel Adoptions, LLC may assist me with necessary living expenses during my pregnancy including rent, food and utility payments if allowable in the state of services. A Guardian Angel Adoptions, LLC will also assist me in accessing any local resources that may be available to me during my pregnancy or following the delivery of my child. I understand the agency is limited by law regarding the assistance offered. I understand A Guardian Angel Adoptions, LLC is unable to pay for past bills or deposits. I understand it is my choice to choose one person to support me through my pregnancy and the adoption process, but at any time should my support person be found using, or in possession of drugs or if they become physically or mentally abusive to me, my children, or any member of A Guardian Angel Adoptions, LLC, he/she will be IMMEDIATELY escorted to the nearest bus station to return home. There are no exceptions to this rule. I understand that in signing the "Release of Information" form that I am authorizing any and all psychological, psychiatric and health information or birth certificate records pertaining to me or any child of mine to be released to A Guardian Angel Adoptions, LLC. I understand that A Guardian Angel Adoptions, LLC will provide me with counseling and support me to help me in making decisions concerning my pregnancy. A licensed social worker or a professional counselor will be assigned as my counselor to assist me throughout the adoption process. I give permission for my caseworker and social worker to discuss my case with other staff members of the agency, health care workers, other adoption agencies and law enforcement officers as needed. I understand that services are rendered on a case-by-case basis and that services provided to another birth mother may not be the same as those provided to me. I understand that A Guardian Angel Adoptions, LLC will not disclose my last name, address, phone number or any other identifying information to the adoptive family without my permission; however, they cannot guarantee privacy in any adoption. If I place my child with A Guardian Angel Adoptions, LLC I may be involved in the selection of an adoptive family. I understand that non-identifying information about the other birth parent, the pregnancy, and myself will be shared with any family I may be considering as potential parents for my child. I have signed or will sign a release of information, allowing information specifically for this purpose. Adoptive Placement: A Guardian Angel Adoptions, LLC will assist me in selecting the adoptive parents who match my request, though they cannot guarantee all my preferences will be met. All adoptive parents have been thoroughly screened by A Guardian Angel Adoptions, LLC and found appropriate for the placement of my child. A Guardian Angel Adoptions, LLC P.O. Box 95902, South Jordan, UT 84095 Statements of Understanding 6
Adoptive Placement (cont): I understand that based on Utah Law, A Guardian Angel Adoptions, LLC may not place a child with anyone who is cohabiting in a relationship that is not a legally valid and binding marriage under the laws of Utah. Cohabiting is intended to mean residing with another person and being involved in a sexual relationship with that person. I understand I have the option to choose the adoptive parents. If I forgo this choice, A Guardian Angel Adoptions, LLC will choose the adoptive parents they feel most appropriate to adopt my child. Religion Statement: I understand and agree that A Guardian Angel Adoptions, LLC is placing my child with a family that may or may not practice religion as I do and that the adoptive parents will raise my child in the faith of their choice. A Guardian Angel Adoptions, LLC does not discriminate against adoptive families because of religious affiliation. Elective Post Operative Surgery: I understand that if I choose to have an elective post operative surgery, I will be responsible for all associated charges incurred. Elective post operative surgery is not considered an adoption related expense, and therefore, CANNOT be reimbursed. Services Provided: I understand that staff members of A Guardian Angel Adoptions, LLC who are providing me services may also be providing services to the adoptive family. I also understand that such an arrangement might create a conflict of interest between my concerns and the concerns of the adoptive family. Irrevocable Relinquishment: Openness Agreement: Post-Placement Arrangements: If I decide on an adoption plan for my child, I will sign the relinquishment papers. I understand that I must wait at least 24 hours following the delivery of my child to sign the relinquishment papers. I realize that when I sign the relinquishment and consent paperwork, all my rights and responsibilities to this child will end and that my consent to adoption will be final, irrevocable and legally binding. I understand that A Guardian Angel Adoptions, LLC will assist in working with the adoptive family in regards to the openness agreement by setting up a post-placement plan that meets my specific needs. A Guardian Angel Adoptions, LLC will facilitate the exchange of pictures, letters and phones calls for the birth mothers and adoptive families. I understand that in Utah, openness agreements are not legally binding. I understand A Guardian Angel Adoptions, LLC will provide housing for up to ten days after I place my child for adoption. I will also be given a reasonable amount of financial assistance to help me for up to six weeks following my placement. Additionally, I understand that A Guardian Angel Adoptions, LLC will provide me with transportation back to my home or place of choice. Other post-placement services include facilitation of openness agreement and up to three post-placement counseling visits and/or appropriate counseling and community referrals. Statement of Promises: There have been no promises made to me that would influence my decision to place my baby for adoption. I have not been offered gifts or promises for placing my child for adoption. I understand that gifts or allowances beyond the guidelines set by A Guardian Angel Adoptions, LLC cannot be accepted. Utah Mutual Consent Registry: I understand the Utah Mutual Consent Registry makes it possible for the birth parents and adoptee to be reunited when the adoptee is 18 years of age. I understand that contact will be possible through this resource only if both adoptee and birth parent register. I understand it is my responsibility to initate my desire to be listed with the registry, which is administered by Utah Vital Records. Yes / No (please circle one) Legal Advice: I understand that I have the legal right to consult with an attorney of my own choice and to seek independent legal counsel prior to making the decision to place my child for adoption. A Guardian Angel Adoptions, LLC P.O. Box 95902, South Jordan, UT 84095 Statements of Understanding 7
Birth Father I understand A Guardian Angel Adoptions, LLC reserves the right to discontinue services Information: if for any reason the initial birth father information I provide, is not consistent with fact. Information I understand A Guardian Angel Adoptions, LLC reserves the right to discontinue Provided: services if for any reason the information provided, is not consistent with fact or actions. Information on I understand A Guardian Angel Adoptions, LLC reserves the right to discontinue Marriage: services if the information provided about any marriages I am in, or have been in are not consistent with the facts. Medical Expenses: I understand that if I decide not to place my child for adoption, I will be responsible for all medical expenses incurred for me and my child. Other Expenses: If for any reason, I choose to parent my baby, I will be responsible for all expenses related to caring for myself, my baby and any other individual that accompanied me to Utah. This includes, but is not limited to, housing and living expenses, baby necessities, and previous, current and future medical care. I agree to find housing/hotel until I leave Utah. Transportation to the city I came from will only be provided by Greyhound Bus service. after I have been medically cleared to travel. No exception to this policy is premitted. Signatures I, am not under the influence of any drugs, alcohol or medication that may influence my reasoning or judgment and am signing this document of my own free will and choice. Birth mother's name (please print) Birth mother's signature Date: Birth father's name (please print) Birth father's signature Date: A Guardian Angel Adoptions, LLC P.O. Box 95902, South Jordan, UT 84095 Statements of Understanding 8
Birth Mother Release of Information Authorization For Release of Information TO: ANY PHYSICIAN, MEDICAL FACILITY, PSYCHIATRIST, PSYCHOLOGIST, ADOPTION AGENCY, FEDERAL, STATE, COUNTY OR CITY AGENCY, ATTORNEY OR LAY PERSON. You are hereby authorized to release to the following agency: A Guardian Angel Adoptions, LLC P.O. Box 95902 South Jordan, Utah 84095 Phone: (801) 756-7757 Fax: (801) 568-0567 Any and all psychological, psychiatric, health information or birth certificate record pertaining to me or any child of mine which is now, or in the future may be, in your possession and are further authorized to verbally discuss any interaction you have had or may have with me. It is hereby expressly authorized to copy or receive copies of any records or documents pertaining to me or the information specified above. This information may be used in connection with any proceeding concerning the adoption, guardianship, custody and control of my child. You are also authorized to release information to the individual or couple that adopts my child, as identified by the Placement Agreement between A Guardian Angel Adoptions, LLC and the adoptive party. MEDICAID If requested, I authorize Medicaid to release information about me or my children to A Guardian Angel Adoptions, LLC. I authorize Medicaid to provide them my Medicaid number and any other information about my case. I understand that if I apply for Medicaid in Utah, my benefits in another state will be cancelled. CHILD'S GENDER I authorize the OB/GYN, RN or ultrasound technician to tell A Guardian Angel Adoptions, LLC the gender of my unborn child if requested, even if I choose not to know myself. I also authorize any other adoption agency, counselor, attorney or other professional who is contracted by A Guardian Angel Adoptions, LLC to release information about me, my child(ren), or this adoption to A Guardian Angel Adoptions, LLC. In addition, I authorize A Guardian Angel Adoptions, LLC to release information about me to other adoption agencies if I have contacted them for assistance. This Authorization shall remain valid for two years from this date. SIGNATURE Birth mother's name (please print) Birth mother's signature Date