Order Placing Surrendered Newborn With Prospective Adoptive Parents {CCFD 02}

Approved, SCAO STATE OF MICHIGAN FILE NO. JUDICIAL CIRCUIT - FAMILY DIVISION ORDER PLACING 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 chld 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 CCFD 02 (1/01) ORDER PLACING SURRENDERED NEWBORN WITH PROSPECTIVE ADOPTIVE PARENTS MCL 712.7