Child Registration/Update Form

CY 130 4/14 Page 1 of 5 Child Registration/Update form (CY 130)STATEWIDE ADOPTION ANDPERMANENCY NETWORK MAIL TO: PENNSYLVANIA ADOPTION EXCHANGE, BOX 4469, HARRISBURG, PA 17111-0469 | 1-800-227-0225 SWAN ID # DHS # PAE ID # Child DEMOGRAPHICSCHILD S LAST NAMECHILD S FIRST NAMEMIALIAS (if TPR pending or under appeal - FIRST NAME ONLY)DATE OF BIRTHSOCIAL SECURITY # (requested)GENDER Male FemaleRACE AND ETHNICITY (Check all that apply)RACE: American Indian/Alaskan Native Asian Black/African American Native Hawaiian/Other Pacific Islander White Unable to determineETHNICITY: Hispanic Non-Hispanic Unable to determineSiblings (to be placed with Child )NAMEDATE OF BIRTHNAMEDATE OF BIRTHAGENCY INFORMATIONCOUNTY CHILDREN AND YOUTH AGENCYCOUNTY CASEWORKER (Full name)MAILING ADDRESSEMAILCITYSTATEZIP CODETELEPHONE #FAX #( )( ) Child Specific Recruitment Agency (if different from county children and youth agency)AGENCY NAMECASEWORKER (Full name)MAILING ADDRESSEMAILCITYSTATEZIP CODETELEPHONE #FAX #( )( ) Child S PRIMARY GOALDATE CURRENT GOAL ESTABLISHED Goal under appealDATE Reunification Adoption PLC Fit & willing relative APPLACHILD S CONCURRENT GOALDATE CURRENT GOAL ESTABLISHED Goal under appealDATE Reunification Adoption PLC Fit & willing relative APPLACY 130 4/14 Page 2 of 5 Child S STATUSESC urrent Placement Pre-adoptive home (kinship) Pre-adoptive home (non-kinship) Foster care (kinship) Foster care (non-kinship) Institu

page 1 of 5 cy 130 4/14 child registration/update form (cy 130) statewide adoption and permanency network mail to: pennsylvania adoption exchange, p.o. box 4469, harrisburg, pa 17111-0469 | 1-800-227-0225 swan id # dhs # pae id # child demographics

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