Adoption Services Referral Form
Adoption Services Referral Form

Adoption Services Referral Form

    Please select all that apply.
    A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
  • Termination of Parental Rights:

    *Please note that if a child under the age of six does not meet two or more of the following criteria, a special approval request (SAR) must be made to VDSS by DePaul Community Resources prior to opening the case. VDSS approval to open a SAR case is not guaranteed.
  • Please list the special needs of this child:

  • *If "siblings" box checked, please provide their name and date of birth.
  • Please Read and Check Below Indicating Agreement With and Consent to the Following:

    DePaul Community Resources has permission to photograph and/or videotape the child/children referred and to feature them in the media, including internet, television, print, radio, electronic and other public venues, for the purpose of locating an adoptive family.
    DePaul Community Resources agrees that the use or disclosure of any information concerning children or families serviced by DePaul Community Resources will be used for adoption purposes only.
  • Providing your initials above represents your digital signature for this form.