Free ccfd02.pmd - Michigan

Approved, SCAO

JIS CODE: ONA

STATE OF MICHIGAN
JUDICIAL CIRCUIT - FAMILY DIVISION

COUNTY

ORDER PLACING SURRENDERED NEWBORN WITH PROSPECTIVE ADOPTIVE PARENTS

FILE NO.

In the matter of
Full name of child

, a surrendered newborn child

1. Date of hearing:

Judge:
Bar no.

2. A petition requesting an order for authority to place the child with prospective adoptive parent(s) has been filed by , a child-placing agency.
Name of agency

3. The child was born on
Date

Date

and was surrendered to an emergency service provider on .

4. THE COURT FINDS that an order to place the child and to provide care for the child is necessary. IT IS ORDERED: 5. The child-placing agency is authorized to place the child with the prospective adoptive parents,
Name(s)

, residing at
Address

.
City, state, zip

6. The child-placing agency and the prospective adoptive parent(s) shall provide care for the child and each is authorized to consent to all medical, surgical, dental, optical, psychological, educational, and related services. 7. The child-placing agency shall supervise the child in the home of the prospective adoptive parent(s) and shall report to the court as directed. The child shall not be removed from the home without court order and shall not be removed from the State of Michigan.

Date

Judge

Do not write below this line - For court use only

CCFD 02 (9/07)

ORDER PLACING SURRENDERED NEWBORN WITH PROSPECTIVE ADOPTIVE PARENTS

MCL 712.7