A. CHILD STUDY REPORT

To be submitted to the court after being countersigned by the adoptive applicants Photograph of the child to be countersigned by both parents.

Name and address of the institution:

I. General information :

1. Name of the child :
   
2. Reference no. as per general register of the institution
   
3. Present age and date of birth:
   
4. Sex:
   
5. Religion(if known):
   
6. Where was the child born (institution, hospital, home):
   
7. In whose care is the child at present? If in foster care, state reasons why it had to be removed from the institution and the date on which it was removed:

II. Legal data :
(For court committed or remand children only)

1. Is the child on remand or committed to your institution:
   
2. Name of the committing court:
   
3. Age of the child at the time of Commitment:
   
4. Date of order of Commitment:
   
5. Period of Commitment:
   
6. Final date of release:
   
7. Section of the Juvenile Justice Act, 1986:
   
8. Date of admission to your institution.

Please enclose a copy of the Court Commitment Warrant:
If available, please enclose a copy of the Probation Officer’s report which he/she submitted to the Juvenile Court at the time of commitment of the child as also the Commitment Order for the court.

III. Social data :
Do not give identifying information such as name and address of the natural parent

1. Date of admission of the child to your institution:
   
2. How did the child come to your institution:

1. admitted directly by parent or any other guardian?
   
2. placed on remand or court committed or referred by the police? (Name of the committing court or police station should be given).
   
3. transferred from any other institution, and if so which one?
   
4. any other source?

3. Circumstances under which the child came to the original institution:
   
4. Reasons for seeking protection in the institution:
   
5. Available information on biological parent’s physical and mental health (if any history of mental illness, ailments such as diabetes, epilepsy, heart condition, etc.):
   
6. Social information about the relatives (including health and medical condition of the immediate family of the child’s biological parents):
   
7. In case relatives are alive, have they agreed to give away the child in adoption/guardianship and if so, whether written consent has been obtained:
   
8. Whether the relatives have established any contact with the child after his/her admission to your institution:
   
9. If the child is purely destitute, give information which will prove this:
   
10. If the child was abandoned some time after birth, say about 10 days, give details of how the child was being cared for during the intervening period:

IV. Physical and emotional development:

1. Attitude towards other inmates:
   
2. Relationship with relatives, staff and other adults including strangers:
   
3. Intelligence (if and where possible, I.Q. report should be enclosed):
   
4. If the child is school-going, give a detailed report of his/her standard, attendance, general interest in studies, progress, limitations if any:
   
5. General personality and description of the child:
   
6. Play activity and any specific talent:
   
7. Milestones of the child (for children below 18 months): Please mark yes/no
   Does the child...?

1. smile
   
2. turn over on its stomach
   
3. lift its head
   
4. grasp objects in its hand
   
5. crawl on its own
   
6. sit with support --------- without support ---------
   
7. stand with support ------- without support -------
   
8. walk with support -------- without support -------

8. Language development:

1. babbles incoherently
   
2. speaks few words incoherently
   
3. speaks few words clearly
   
4. speaks fluently
   
5. language/s spoken by the child

9. Dietary habits:
   Intake of : Liquid foods ----------- Semi solids -------- solids --------
   
10. Physical examination report (appended)
    I, Shri/Smt. ----------- , of ---------- (name of agency), do hereby certify that the information given in this form 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 as our adoptive child ------------------------ (fill in child’s name).
    (Signature of the male applicant) (Signature of the female applicant)
    (Name of the male applicant) (Name of the female applicant)
    Place:
    Date:

B. MEDICAL REPORT OF THE CHILD

Physical examination report (to be filled in by the examining physician)
Name of the child:
Sex:
Age:
Colour: skin ------ eyes ------ hair -----
Height:
Weight:
Head:
Feet:
Circumference (any defect):
Vision(number and condition):
Nose:
Teeth:
Chest:
Posoture:
Heart:
Spine:
Nervous System:
Legs:
Reflexes:
Abdomen:
Hearing (any defects):
Any other:
Immunizations:
B.C.G.:
Measles:
Triple Antigen:
Poliomyelitis:
Tests (to be completed wherever possible)
VDRL:
Tuberculosis:
Chest X-rays:
Urine analysis:
Stool:
Blood:
HIV:
H.P.B.:
Medical evaluation (pertinent information regarding the child’s physical condition):
General condition of mental and physical development observations of physician:

Date:
Physician’s signature:
Place:
Registration number:

We have read and understood the contents of this Physical Examination report and are willing to accept ----------- (fill in name of the child) with his/her given condition.
(Signature of the male applicant) (Signature of the female applicant)
(Name of the male applicant) (Name of the female applicant)

C. BIRTH AFFIDAVIT OF THE CHILD

I, Mr. ---------------, residing at -----------, Bombay, do hereby state on solemn affirmation as follows:

1. I say that I am the father of female minor born on ----------.

2. I say that the date of birth of my daughter is -------------. There is no other document or record stating the said date of birth of the said minor and no such other document can be traced by any amount of diligence.

3. It is therefore the intention of this document that it be used as Birthdate Certificate for all purposes allowed by the Law including the child’s school admission purpose.
Solemnly affirmed at Bombay
on this 13th day of December, 1990.
Before me

Notary

D. DOCUMENT OF SURRENDER (SINGLE PARENT)*

I, -------- aged ------- do hereby state as follows:

1. I delivered a child on ------- at ------. The said child is born out of wedlock and has been in my guardianship and custody thereafter.
   
2. I request the authorities not to disclose my full identity or address or whereabouts and do not wish to give any information of the father, or other relatives of the said child, because of social reasons.
   
3. I am the sole guardian of the said child and there is no other lawful guardian or father for the said child.
   
4. I say that I was helped by the authorities of Family Service Centre, Eucharistic Congress Building Number 3, 5 Convent Street, Colaba, Bombay 400 039 to understand all implications of adoption of my child and I was specifically told that in case the minor whom I am abandoning, if adopted, I shall have no further contact with the minor. I have made this decision of abandoning the minor after due thought and consideration.
   
5. I say that I, without receiving any monetary and material consideration voluntarily of my own free will and volition and without any inducement, influence, coercion or fraud and without being under the influence of any person, drink or drug, have today handed over my aforesaid child to Family Service Centre, Eucharistic Congress Building Number 3, 5 Convent Street, Bombay 400 039 with the authority to Family Service Centre, Bombay to place the said child in adoption / guardianship with any suitable people.
   
6. I say that I have abandoned the said child because I am unable to look after, maintain, educate and bring up the child and have no relative, friend willing to do so. I further say that I was explained and given to understand that I can claim my child within three months from today. I have further been explained that if I do not reclaim my child during this period of three months the agency will be free to rehabilitate the child at its own discretion either in India or abroad. I further state that should any untoward event occur with regard to the child when in the agency’s foster care, I shall not hold the agency responsible.
   
7. I hereby declare that I have relinquished all my rights and claims to the said child and all reciprocal rights, claims and/or obligations of the parent and child between me and the said child are terminated. The authorities of Family Service Centre, Eucharistic Congress Building Number 3, 5 Convent Street, Bombay 400 039, may in their discretion place the said child into any good family irrespective of religion, in India /abroad, or transfer the child to any institution for the purpose of adoption/guardianship or any suitable rehabilitation.

• *The sample documents are derived from the records of the Family Service Centre,Bombay.

8. I request the authorities of Family Service Centre, Bombay, not to disclose my name and identity, known to them, to person or persons or authority at any time and under any circumstances.
Read over and explained by me-

Full name:
Designation:
Address:
Witnessed by:
Full name:
Designation:
Address:
Dated this day of 1992:
Natural mother’s name , signature/thumb impression:
Signature.thumb impression of natural mother’s relative:

DOCUMENT OF SURRENDER (MARRIED COUPLE)

1. We, Mr. --------, aged --- years and Mrs. ----------, aged --- years do hereby state as follows :
   
2. We have been married for five years. We have two children, a female child aged four years, and a male child aged one and a half years. We say that with much thought and consideration, we have decided to give up our third child, that is, a female child, born on --------, in adoption. We are the sole guardians of the child and there is no other lawful guardian for the said child.
   
3. I am working as a newspaper vendor at Dadar and have no permanent shelter. My wife is in long-term hospital care since she is suffering from an advanced stage of tuberculosis which is terminal. My wife and I are finding it very difficult to provide for and look after three children. We have been explained that some kind of support and foster care can be arranged by Family Service Centre, in case we do not wish to abandon this child. However, in the best interests of the child, we have decided, by our own free will, to give up the said baby girl in adoption.
   
4. We say that we are helped by the authorities of Family Service Centre, Eucharistic Congress Building Number 3, 5 Convent Street, Colaba, Bombay 400 039, to understand all implications of adoption of our child and we were specifically told that in case the minor whom we are abandoning, if adopted,we shall have no further contact with the minor.
   
5. We request the authorities not to disclose our full identity or address or whereabout and do not wish to give any information of ourselves because of social reasons.
   
6. We are aware that the Family Service Centre will act in the best interests of the child. However, in unforseeable circumstances, we shall not hold the agency responsible.
   
7. We say that without receiving any monetary and material consideration voluntarily, of our own free will and volition and without inducement, influence, coercion, or fraud and without being under the influence of any person, drink or drug, have handed over our aforementioned child to Family Service Centre, Eucharistic Congress Building Number 3, 5 Convent Street, Colaba, Bombay 400 039, with the authority to Family Service Centre, Bombay, to place the said child in adoption / guardianship with any suitable couple.
   
8. We say that we have abandoned the said child because we are unable to look after, maintain, educate and bring up the said child and have no relative or friend willing to do so. We further say that we were explained and given to understand that we can claim our child within four months from today. We have further been explained that if we do not reclaim our child during this period of four months, the agency will be free to rehabilitate the child at its own discretion either in India or abroad.
   
9. We hereby declare that we have relinquished all our rights and claims to the said child and all reciprocal rights, claims and / or obligations of the parent and child between us and the child are terminated. The authorities of Family Service Centre, Eucharistic Congress Building Number 3, 5 Convent Street, Bombay 400 039, may at their discretion place the said child into any good family irrespective of religion, in India / abroad or transfer the child to any institution for the purpose of adoption / guardianship or any suitable rehabilitation.
   
10. We request the authorities of Family Service Centre, Bombay, not to disclose our name and identity, known to them, to person or persons or authority at any time and under any circumstances.

Read over and explained by me-

Full name:
Designation:
Address:
Witnessed by:
Full Name:
Designation:
Address :
Witnessed by:
Full Name:
Relative of natural parents:
Address:
Natural mother’s name, signature/thumb impression:
Natural father’s name, signature/thumb impression:
Dated, this day of July 1991:

RELEASE DOCUMENT FOR CHILD ON REMAND

IN THE COURT OF THE METROPOLITAN MAGISTRATE: JUVENILE COURT:
UMERKHADI:BOMBAY; CASE NO. 333J/88

B/J was produced before this Court by Matunga Police station on 4-9-1988 and he was transferred to the Observation Home. Thereafter, he was transferred to A.O.H. on 6-10-1988. His photo was telecasted on television on ------- 1989. Till this date nobody has turned to enquire about him to take his custody. It, therefore, clearly appears that he is abandoned by his parents and relatives. He is therefore, declared as a destitute child.

Sd/-
Metropolitan Magistrate
Juvenile Court, Umerkhadi
Bombay

RELEASE DOCUMENT OF COURT COMMITTED CHILD

Social Welfare, Cultural Affairs, Sports and Tourism Department, Sachivalaya Annexe, Bombay 400 032
Bombay Children Act: 1948*
No. BCA 2376/13960-D-X: whereas the Metropolitan Magistrate, Juvenile Court,
Umerkhadi, by his order dated the 10-10-79 made under section 45 of the Bombay Children Act, 1948 (Bom. LXXI of 1948) committed the male /female child named to the care of the home, Bombay for the period ending 2008.
And whereas Mr. and Mrs. ---------- residents of (hereinafter called the custodians) have requested that the said child be given to them for care and custody and have agreed that the said male / female child will be taken care of as if s/he were their own child.
And whereas the Director of Child Welfare, Maharashtra State, Pune, has moved the State Government for release of the said male/female child to the care of the custodians after having satisfied himself about their bonafide intention and they are fit persons.
Now, therefore, in exercise of the powers conferred by subsection (1) of section 97 of the Bombay Children’s Act, 1948 and of all other powers enabling it in this behalf the Government of Maharashtra hereby order the said male /female child to be discharged from the Home and directs the authorities of the said Home to entrust him to the case of the custodians with the following instruction:

1. 1) That the custodians shall provide for the facilities of instructions to the child in his religion as envisaged in subsection (1) of section 91 of the Bombay Children Act, 1948 and shall execute a bond to that effect.
   
2. 2) That the custodians shall give a copy of photograph of the child to the Director of Child Welfare, Maharashtra State, Pune, while removing the child from the Institution.
   
3. 3) That the custodians shall send report about the progress of the child every year to the Director of Child Welfare, Maharashtra State, Pune.

By order and in the name of the Governor of Maharashtra,
Sd. ()
Under Sect. to Government of Maharashtra

To,

The Director of Child Welfare, Maharashtra State, Pune
The Divisional Social Welfare Officer, Pune
The Executive Secretary, ICSW, 175, D.N. Road, Bombay
The Superintendent , of the ------ Home, ---------- Bombay
Mr. and Mrs. (the custodians’ address)

• *Replaced by the Juvenile Justice Act, 1986

E. COURT ORDER: UNDER HINDU ADOPTION AND MAINTENANCE ACT,1956

IN THE BOMBAY CITY CIVIL COURT AT BOMBAY