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

Registration of Placement of a Child for Adoption

Subsection 183(7) of the Child, Youth and Family Services Act, 2017

I/We
Name of society or licensee
have placed a child with the person(s) named herein on the understanding that such person(s) will adopt the child.

I/We hereby register the placement of the child with you and make the following statements in respect thereof:

1. My address/the address of the agency is

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

2. The name of the child is
(Full name as on statement of Live Birth)

Last Name
First Name
Middle Initial

3. The child was born at

City/town
on the Day day of Month Year

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. 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

6. I

am /or am not related to the child. If related, what is the relationship?

I placed the child on the Day day of Month Year

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

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?

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

Yes No

If yes, signed on Day day of Month Year

9. Did the parent referred to in paragraph 5 above consent to the placement and adoption?

Yes No

If yes, signed on Day day of Month Year

10. 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)

11. If the child is a child in extended society care, what is the date of order that placed the child in extended society care?
Date (yyyy/mm/dd)

12. 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