Initial

Statement

1. Placement Services: I am expecting a child to be born on or around

I am seeking out the professional services of Adoption & Beyond, Inc. (hereafter “the Agency”) in planning my own unique adoption plan for the placement of my child. I understand that the Agency has a Child Placement Program designed to help expecting parents make an adoption plan for their child. I would like to participate in this program and I do so freely and voluntarily. I agree to cooperate fully with Agency staff. I am aware that signing this document will in no way obligate me to place my child with the Agency or any other agency or individual for the purpose of adoption.

2. Right to Parent: As the expecting parent of my child, I know I have the primary right to parent my child. I understand that there are community resources and financial assistance available to parents who elect to parent their children. I understand that I am free to change my mind, for any reason and at any time, prior to signing my legal relinquishment paperwork.

3. Fraud: I understand that misrepresenting my pregnancy or my desire to place my child for adoption is considered fraud. I also understand that receiving assistance and support or planning an adoption with more than one adoption agency and/or hopeful adoptive family at the same time may be fraud. I understand that adoption agencies may share information with other agencies in an effort to prevent fraud. The Agency may choose to prosecute me if I have committed a fraudulent act.

4. Adoption Coordinator: I understand that the Agency will provide me with a Licensed Social Worker who will educate, support and help guide me in making decisions concerning my adoption plan.

5. Living Expenses: I fully understand that it is illegal to solicit or receive any kind of fee in return for placing my child for adoption. The law does allow a hopeful adoptive family to assist with current pregnancy-related living expenses during my pregnancy and up to six (6) weeks following delivery, including food, shelter, clothing and transportation to medical appointments. I understand the hopeful adoptive family is limited by law regarding the assistance offered. I also understand that the Agency assumes no financial responsibility for expecting parents involved in their child placement program.

6. Medical Expenses: If I do not currently have medical coverage, the Agency will assist me in trying to secure medical coverage for my pregnancy. This may include applying for Medicaid and, if applicable, I agree to work cooperatively to do so. I agree that if I have medical insurance coverage or Medicaid, I will use it to pay for mine and the baby’s medical expenses to the extent possible. I understand that whatever the adoptive family pays towards my medical expenses will be paid directly to the health care provider. I understand that medical expenses will not be paid if I have a miscarriage. I understand that other than co-pays, the hopeful adoptive family will not pay for medical expenses until the time of placement. In the event that I choose to parent the child, neither the Agency nor the hopeful adoptive family are liable for any outstanding medical expenses I may have.

7. Irrevocable Relinquishment: If I decide on an adoption plan for my child, I will sign legal relinquishment paperwork. I understand that I must wait at least twelve (12) hours in Kansas and forty-eight (48) hours in Missouri following the delivery of my child to sign the legal relinquishment paperwork. I realize that when I sign those documents, all my rights and responsibilities to this child will end and that my relinquishment will be final, irrevocable and legally binding.

8. Adoptive Family Selection: The Agency will assist me in viewing hopeful adoptive parents who best match my preferences and situation. The Agency cannot guarantee all my preferences will be met. I know there are no perfect parents. I understand that all hopeful adoptive parents presented have been thoroughly screened by the Agency and found appropriate for placement. I understand I can select and meet the hopeful adoptive parents. If I forgo this option, the Agency will choose the hopeful adoptive parents that are most appropriate to adopt my child.

9. Information Sharing: I agree to provide medical, social and pregnancy related information to the Agency. This information will be shared with the hopeful adoptive parents and other professionals related to this adoption process. I have or will sign a release of information. I will assist and cooperate with the Agency in collecting information important to this adoption process. I understand the importance of sharing truthful and accurate information. I understand if I provide false statements to the Agency or the courts, I may be subject to penalty of perjury. After placement, I know the importance of notifying the Agency of any changes in my health that may affect my child. In addition, I agree that the Agency can reach out to me over the years on behalf of the adoptive family or my child.

10. Confidentiality: I understand that the Agency will not disclose my address, phone number or certain other identifying information to the hopeful adoptive family, or any other professionals related to the adoption process, without my permission. I understand the Agency cannot guarantee confidentiality in any adoption.

11. Contact with Adoptive Parents: Arrangements and understandings established with the adoptive parents are based on good will and are not enforceable in Kansas, however, with the creation of a post-adoption contact agreement prior to finalization of the adoption, they are enforceable in Missouri if a PACA is created. I understand that the Agency will make reasonable efforts to encourage the adoptive parents to comply with any agreements made for contact and exchange of information. I understand the Agency cannot guarantee contact and exchange of information will be upheld by family in either state.

12. Promises: I wish to state that there have been no promises made to me that would influence my decision to place my baby for adoption. I have not been offered gifts or promises for placing my child for adoption. I understand that gifts or allowances, beyond the guidelines set by the law, cannot be given.

13. Withdrawal: I understand that prior to relinquishing my child for adoption, I may discontinue the adoption process. I understand that the hopeful adoptive parents have a similar right to withdraw from the proposed adoption plan at any time. In addition, I know the Agency is free to withdraw its support of an adoption plan at any time.

14. Liability: I acknowledge that the Agency is providing services to me in good faith and I do not hold them responsible or liable in any way for any harm or accident that may come to me during my association with them. In addition, I understand that the Agency is not responsible for the actions of the adopting family or their associates.

15. Services: I understand that the laws pertaining to adoption may change in such a fashion as to alter the Agency’s manner of providing services. I also understand that services are rendered on a case-by-case basis and that services provided to another client may not be the same as those provided to me.

16. Alcohol and Drug Use: I understand that the use of alcohol or illegal drugs during pregnancy is harmful to me and the baby’s health.

17. Policies and Procedures: I acknowledge that the Agency reserves the right to change its policies and procedures at any time without permission or prior notification.

18. Grievance Procedures: I know that preparing for a possible adoption can be an emotionally draining and a complicated process. Although I understand that the Agency strives to empower both expecting parents and hopeful adoptive family to make decisions, there are many times in which families depend upon the Agency staff for support and guidance. I know that as a safeguard, the Agency offers a grievance procedure for anyone wishing to make a formal complaint regarding the Agency’s services. I acknowledge that I have been provided with a copy of the grievance procedure and form.

19. Permission: I give permission for my adoption coordinator to discuss my case with other staff members of the Agency, health care workers or other adoption agencies and law enforcement officers as needed or warranted.

20. Accepting Custody: I understand that the Agency is under no obligation to accept the relinquishment of my child. The following are circumstances that may result in the Agency not accepting a relinquishment:

a. If the child is born with severe special needs; I understand that the Agency will make reasonable efforts to help me find an adoptive family who can meet the child’s needs. I acknowledge that if the Agency is unable to find an approved family, they will make a reasonable attempt to locate another agency who is able to accept custody of my child.

b. If the birth father is actively seeking to gain custody of the child and has expressed his intentions prior to or immediately after the birth of the child; I understand that the Agency may not be able to accept custody of the child until the situation is resolved.

I understand there may be other circumstances not listed here that could result in the Agency not accepting custody.

21. Services Provided By: I understand that staff members of the Agency who are providing me services may also provide services to the hopeful adoptive family. I also understand that such an arrangement might create a conflict of interest between my concerns and the concerns of the hopeful adoptive family. I know I have the right to request a different staff member if a conflict should arise.

22. Birth Father Rights: I understand that according to the adoption laws of the states of Kansas and Missouri the birth father may have the option of parenting the child if he is known, his paternity has been confirmed and he has supported me and/or the child. Furthermore, I understand that if I am withholding information about mine or his whereabouts, I may be putting an adoptive placement in jeopardy. Also, if I am married, my legal husband must be contacted about consenting to an adoption even if he is not the child’s biological father.

23. Consent: I acknowledge that if I relinquish my child for adoption to the Agency, that the Agency will consent to the placement of my child with the hopeful adoptive family once they have paid the placement and any other fees due to Agency.

24. Legal Representation: I understand that an attorney will be provided to me free of charge. My attorney will explain my legal rights and responsibilities prior to the decision to place my child for adoption.