Free Agreement to Participate in Mediation - New Hampshire

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THE STATE OF NEW HAMPSHIRE
JUDICIAL BRANCH
http://www.courts.state.nh.us

Court Name: Case Name: Case Number:
(if known)

AGREEMENT TO PARTICIPATE IN MEDIATION
Abuse/Neglect Minor guardianship Termination of Parental Rights

NOW COMES THE DIVISION FOR CHILDREN, YOUTH AND FAMILIES ("DCYF") AND THE PROSPECTIVE ADOPTIVE PARENT(S) OF THE MINOR CHILD(REN) IN THE ABOVE CAPTIONED MATTER, BY AND THROUGH DCYF, AND HEREBY STATE AS FOLLOWS: 1. DCYF is a party in the above captioned matter involving: and/or
Birth or Legal parent Birth or Legal Parent

2. DCYF and the prospective adoptive parents agree to participate as parties in the mediation session requested by the birth parent(s)/legal parent(s). 3. DCYF acknowledges that it has notified the child (if 14 years old or older) of the date of the mediation session, and has notified the child that he or she may participate in the mediation process. 4. The child does does not wish to participate in the mediation process.

Date

Division of Children Youth and Families

Date

Prospective Adoptive Parent

Date

Prospective Adoptive Parent

Date

Child (14 years old or older)

Date

Signature of Judge

NHJB-2543-F (10/15/2008)

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