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

Director’s Registration of Placement of Child for Adoption

Under Subsection 183 (8) of the Child, Youth and Family Services Act, 2017

Last Name
First Name
Middle Initial ,

Director, hereby register the placement of the following child and make the following statements in respect thereof:

1. The name of the child is
(Full name as on statement of live birth)

Last Name
First Name
Middle Initial

2. The child was born at

City/town
on the Day day of Month Year

3. The following person is a parent of the child

Last Name
First Name
Middle Initial

who resides at

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

4. The following person is a parent of the child

Last Name
First Name
Middle Initial

who resides at

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

5. I have become aware that, on or about Date (yyyy/mm/dd) , the child was placed with

(Full given names and surnames of person(s) with whom child was placed)

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

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

who resides at

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

and who is (are)

single / spouses within the meaning of the Human Rights Code

If related to the child, what is the relationship?

6. This placement was not made by a society or a licensee and was never registered. As I understand it, the circumstances of this placement were:

7. Did the parent named in paragraph 3 above consent to the placement and adoption?

Yes No

If yes, signed on Day day of Month Year

8. Did the parent named in paragraph 4 above consent to the placement and adoption?

Yes No

If yes, signed on Day day of Month Year

9. Is any other individual(s) required, under
the Act, to give consent?

Yes No If yes,

Last Name
First Name
Middle Initial
Describe relationship

Consent signed Consent signed Yes Consent signed No

If yes, signed on Day day of Month Year

(If more than one individual, please add information on reverse side)

10. Name and addresses of person(s), institution(s) or society(ies) that cared for child before placement.

I certify that the above statements are true and correct.

Dated at , this Day day of Month Year

Signature of Witness

Signature of Registrant