Approved, SCAO
JIS CODE: ONA
FILE NO.
STATE OF MICHIGAN
ORDER PLACING
JUDICIAL CIRCUIT - FAMILY DIVISION
SURRENDERED NEWBORN WITH
COUNTY
PROSPECTIVE ADOPTIVE PARENTS
In the matter of
, a surrendered newborn child
Full name of child
1. Date of hearing:
Judge:
Bar no.
2. A petition requesting an order for authority to place the child with prospective adoptive parent(s) has been filed by
, a child-placing agency.
Name of agency
3. The child was born on
and was surrendered to an emergency service provider on
Date
.
Date
4. THE COURT FINDS that an order to place the child and to provide care for the child is necessary.
IT IS ORDERED:
5. The child-placing agency is authorized to place the child with the prospective adoptive parents,
Name(s)
, residing at
Address
.
City, state, zip
6. The child-placing agency and the prospective adoptive parent(s) shall provide care for the child and each is authorized to consent
to all medical, surgical, dental, optical, psychological, educational, and related services.
7. The child-placing agency shall supervise the child in the home of the prospective adoptive parent(s) and shall report to the court
as directed. The child shall not be removed from the home without court order and shall not be removed from the State of
Michigan.
Date
Judge
Do not write below this line - For court use only
ORDER PLACING SURRENDERED NEWBORN WITH PROSPECTIVE ADOPTIVE PARENTS
MCL 712.7
CCFD 02 (9/07)
Approved, SCAO
JIS CODE: ONA
FILE NO.
STATE OF MICHIGAN
ORDER PLACING
JUDICIAL CIRCUIT - FAMILY DIVISION
SURRENDERED NEWBORN WITH
COUNTY
PROSPECTIVE ADOPTIVE PARENTS
In the matter of
, a surrendered newborn child
Full name of child
1. Date of hearing:
Judge:
Bar no.
2. A petition requesting an order for authority to place the child with prospective adoptive parent(s) has been filed by
, a child-placing agency.
Name of agency
3. The child was born on
and was surrendered to an emergency service provider on
Date
.
Date
4. THE COURT FINDS that an order to place the child and to provide care for the child is necessary.
IT IS ORDERED:
5. The child-placing agency is authorized to place the child with the prospective adoptive parents,
Name(s)
, residing at
Address
.
City, state, zip
6. The child-placing agency and the prospective adoptive parent(s) shall provide care for the child and each is authorized to consent
to all medical, surgical, dental, optical, psychological, educational, and related services.
7. The child-placing agency shall supervise the child in the home of the prospective adoptive parent(s) and shall report to the court
as directed. The child shall not be removed from the home without court order and shall not be removed from the State of
Michigan.
Date
Judge
Do not write below this line - For court use only
ORDER PLACING SURRENDERED NEWBORN WITH PROSPECTIVE ADOPTIVE PARENTS
MCL 712.7
CCFD 02 (9/07)