Government of Ontario: Child and Family Services Review Board

Refusal of Adoption Child and Family Services Review Board Application
Child and Family Services Act - Section 144

IMPORTANT NOTICE

Please read the following information before completing this application form.

If you are a foster parent or other person requesting a review of a children's aid society written notice of decision to refuse your application to adopt a particular child,
OR
If you are a person requesting a review of a children's aid society or adoption licensee written notice of decision to remove a child who has been placed with you for adoption,
you must submit this application form to the Child and Family Services Review Board within ten (10) days of receiving the notice of decision, in order to be eligible for review by the Board.

Instructions

1. Please complete all fields as specified;
2. Sign and date form at the bottom;
3. Fax or mail or deliver the form to the address below:
   Social Justice Tribunals Ontario
   Child and Family Services Review Board
   1075 Bay Street, 7^th Floor
   Toronto ON  M5S 2B1
   Telephone: 416 327-4673 or Toll Free: 1 888 728-8823
   Fax to: 416 327-0558

1. General Information

Last Name
First Name
Address (Number and Street)
Suite/Unit/Apt.     City/Town
Province     Postal Code

2. Child Information

Child's Last Name
First Name
Middle Name
Child's Date of Birth (yyyy/mm/dd)
Child's Band or Native Community (if applicable)

3.

Please explain your reasons for requesting a review by the Child and Family Services Review Board. You must explain what you disagree with in the children's aid society or adoption licensee written notice of decision and why. Be as specific as possible. Use the space below and attach additional pages if necessary.

4. Which children's aid society or adoption licensee made the decision you have a complaint about?

Children's Aid Society Name
Children's Aid Society Address (Number and Street)
Suite/Unit/Apt.     City/Town
Province     Postal Code

Adoption Licensee Name
Adoption Licensee Address (Number and Street)
Suite/Unit/Apt.     City/Town
Province     Postal Code

6. Please state the date you received the children's aid society notice of decision or the adoption licensee notice of decision:

Date notice of decision was received: (yyyy/mm/dd)

7. If your application is eligible for review by the Child and Family Services Review Board, will you need any of the following services at the hearing?

• Interpreter No  Yes     Language
  Dialect
  
• Sign Language Interpreter No    Yes
  
• Wheelchair Access No    Yes
  
• Other (Please specify)
  

8. Signature of Applicant (Note: This form must be signed)

Signature

Date (yyyy/mm/dd)

Notice Regarding the Collection of Personal Information
(Freedom of Information and Protection of Privacy Act)

The Child and Family Services Review Board collects the personal information requested on this form for the purpose of conducting a review, under the legal authority of Section 144 of the Child and Family Services Act. It could be shared with participants if a hearing is held. If you have any questions, please contact a Case Coordinator with the Child and Family Services Review Board at 416 327-4673.

The Child and Family Services Review Board does not have the authority to review all children's aid society decisions. The Child and Family Services Review Board will advise you in writing of the reasons if your application cannot be reviewed.

FOR OFFICE USE ONLY

File Number
Date Application Received by the CFSRB