CHILD STUDY REPORT
INFORMATION ON THE CHILD TO BE PLACED
IN GUARDIANSHIP / ADOPTION
1. Name of the Child:
2. Reference No. as per General Register:
3. Date of Birth:
4. How assessed:
5. Place of Birth:
6. Sex
7. Colour of eyes:
8. Colour of hair:
9. Complexion:
10. Weight:
11. Height:
SOCIAL DATA
1. Date of arrival of the child:
2. When and how was the child admitted:
a) Admitted directly:
b) Trasnferred from any other institution
and if so, give particulars:
c) Any other source:
3. Circumstances under which trhe child came to
the original institution:
4. Information about the natural parents, their health, etc., if any:
5. Information about the near relatives, if any:
6. In case if the parents are alive, have they agreed to give away the child in Adoption/Guardianship, if so, whether written consent has been obtained:
7. Whether the natural parents and/or any relatives have established any contact with the child after his/her admission to the institution:
8. Is the child destitute:
9. Any other information:
BEHAVIOURAL OBSERVATIONS
1. How long has the child been with your institution:
2. Physical, intellectual and emocional developement:
ASSESSTEMENT
I (nombre del director del orfanato)______________________________________
hereby certify that the information given in this report about the child is correct.
Place: Signature:
Date: Name:
Designation:
We have read and understood the contents of this Child Study Report and are willing to accept:_____________ (nombre indio del niño/a) as our adoptive child.
________________________ __________________________
(Signature of the male applicant) (Signature of the female applicant)
_________________________ _________________________
(Name of the male applicant) (Name of the female applicant)
Place:
Date:
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