Form Ad 925 Independent Adoption Placement Agreement (Indian Child) Page 3
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3PROSPECTIVE ADOPTIVE PARENT(S) SECTION
I/We, the prospective adoptive parent(s) listed on page one, accept the placement of ______________________________
NAME OF CHILD
by ___________________________________________________________ into my/our home with the intent of adoption.
PLACING PARENT(S)
I/We agree to file a petition to adopt this child within ten (10) working days after signing this placement agreement with the
Superior Court in ______________________________________ County, the county where:
NAME OF COUNTY
I
I/We reside.
I
The child was born or resides at the time of filing.
I
The placing birth parent(s) resided when the Independent Adoption Placement Agreement was signed.
I
The placing birth parent(s) resided when the petition was filed.
I/We agree that if, during the time period specified on the first page of this agreement, the placing parent(s) sign(s) and
delivers to the investigating adoption agency a statement revoking this placement agreement and requesting that the child
be returned, I/we must immediately return the child to the custody of the placing parent(s).
I/We agree that until the adoption is granted by the court:
A.
I/We must place the child under the care of a licensed physician and follow his/her recommendations for health care
for the child, including immunization.
B.
I/We must not take the child from the county named above for a period of more than thirty (30) days without the approval
of the court. I/We understand that the court may issue an order which prevents me/us from taking the child out of the
county at all.
C.
I/We must not conceal the child from the placing parent(s), the investigating adoption agency, or the court.
D.
I/We must inform the investigating agency of any changes in my/our family or place of residence.
E.
I/We must assume responsibility for board, lodging, maintenance, medical care, and any other care for this child, and
for any damages resulting therefrom.
I/We have been informed of the basic health and social history of the placing parent(s).
SIGNATURE OF PROSPECTIVE ADOPTIVE PARENT
DATE SIGNED
SIGNATURE OF PROSPECTIVE ADOPTIVE PARENT
DATE SIGNED
ADOPTION SERVICE PROVIDER SECTION
(witnessing prospective adoptive parent(s) signature)
I, __________________________________________________, have witnessed the signing of this Independent Adoption
NAME OF INDIVIDUAL SERVING AS AN ASP
Placement Agreement by _______________________________________________ on __________________________
PROSPECTIVE ADOPTIVE PARENT(S)
DATE
in _________________________________.
CITY AND STATE WHERE SIGNED
I am:
I
A representative of ________________________________________, a California licensed private adoption agency.
NAME OF AGENCY
I
An individual California ASP.
I
A representative of ___________________________________________, an adoption agency licensed or otherwise
NAME OF AGENCY
approved under the laws of the state of ___________________________________, the state where the Independent
Adoption Placement Agreement is being signed.
NAME OF STATE
I
An individual licensed or otherwise certified as a Clinical Social Worker under the laws of _____________________
the state where the Independent Adoption Placement Agreement is being signed.
NAME OF STATE
I
Independent counsel for the placing parent(s) serving as an ASP, pursuant to Family Code Section 8502(b) and
SIGNATURE OF INDIVIDUAL SERVING AS AN ASP
DATE
AD 925 (8/15) (INDEPENDENT ADOPTION PLACEMENT AGREEMENT)
PAGE 3 OF 3
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