Government of Ontario: Ministry of Children, Community and Social Services

Notice to a Director of Proposed Placement

Section 188 of the Child, Youth and Family Services Act, 2017

To: A Director

I/We
1. Licensee/Last Name
1. First Name
1. Middle Initial

Address

Unit No.
Street No.
Street Name
PO Box
City/Town
Province
Postal Code

Holder of License issued under Part VIII Section 229 of the Child, Youth and Family Services Act, 2017

Propose to place a child

born on born on Date (yyyy/mm/dd)
or
expected to be born on expected to be born on Date (yyyy/mm/dd)

Full given names and surnames of birth parents

1. Last Name
1. First Name
1. Middle Initial

2. Last Name
2. First Name
2. Middle Initial

Address

Unit No.
Street No.
Street Name
PO Box
City/Town
Province
Postal Code

with

Full given names and surnames of applicant(s)

1. Last Name
1. First Name
1. Middle Initial

2. Last Name
2. First Name
2. Middle Initial

Address

Unit No.
Street No.
Street Name
PO Box
City/Town
Province
Postal Code

For adoption

The placement, if approved under section 188, will be supervised by:

Full name of person supervising the placement:

Last Name
First Name
Middle Initial

Date (yyyy/mm/dd)
Signature of Licensee

Information on this form is collected under the legal authority of the Child, Youth and Family Services Act, 2017 for the purpose of administering Ministry of Children, Community and Social Services programs and/or services. For more information contact: Director, Client Services Branch, Ministry of Children, Community and Social Services, 6^th Fl., 101 Bloor St. W., Toronto ON M5S 2Z7 or call 416-326-3170.