Rcpc Form A-1 Application For Placement For Adoption Page 2
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18.3 Consents to the adoption of birth parents with Ohio Law and
Adoption Materials Form ODHS 1693 and RCPC Form A-3 Withdrawal of
Consent and Finality of Adoption Decree will be filed prior to
hearing on proposed placement if the child is under six months of
age; otherwise birth parents will execute such consents and forms in
open court.
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A social and medical history of the applicant(s) (ODHS Form 1616) is
attached and made part of this application.
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Your applicant(s) further state(s) that the child may be examined by
a physician selected by the prospective adoptive parents.
[ ]
Your applicant(s) further state(s) that if the child’s hospital
discharge, subject however, to the approval of the circumcision by
the prospective adoptive parents.
Wherefore, applicant(s) state that it would be in the best interest of the
child if such placement is approved by the Court; that the right to examine
any investigation report on the proposed adoptive parents is waived; and
request that the Court approve the proposed placement and that this
application be set for hearing at the earliest date allowable by law.
Applicant – Birth Mother
Co-Applicant – Birth Father
Typed or Printed Name
Typed or Printed Name
Address
Address
Phone Number (include area code)
Phone Number (include area code)
CERTIFICATION BY ATTORNEY
I certify that I represent only the applicants and do not represent the
prospective adoptive parents.
Attorney for Applicant(s)
Typed or Printed Name
Address
Phone Number (include area code)
Attorney Registration Number
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