CYFD Heart Gallery of New Mexico Portrait Application

Adoption consultants: Please save this blank form as a master and fill it out for each child using MS Word, saving it under the child’s name. Please print a copy of the completed form for the child’s file.

Please send completed form to Diane Granito at

Please notify Diane of ANY pertinent changes including child’s consultant and, if portrait is pending, placement changes

Date:

Note: If this child is part of a sibling group that must be adopted together please give the first and last names of the others in the group in the designated space below and fill out a separate form for each; we will get shots of individual children and any requested combinations if you state there is the possibility of a sibling split. If siblings are already split we will treat each separately and do not need the sibling information.

Child’s first name:

Child’s last name (for internal use only):

Siblings’ full names if being placed together:

Note if individual shots needed and/or requested combinations of siblings:

Children in the Heart Gallery must be legally free. Is this child legally free for adoption at this time?

Child’s FACTS case ID number:

Child’s DOB:

Child’s caseworker:

Child’s adoption consultant:

PLACEMENT DETAILS:

Foster parent(s) name(s):

Address:

Phone(s) (please include cell number if available):

Is this a treatment foster family?

How long has this child been in this placement:

If so, treatment agency name and location:

Children in RTC’s must be at an appropriate behavioral and emotional level for this program. For their own well-being, children in hospitals are not photographed.

RTC name:

RTC address:

RTC phone number:

Name of case worker at RTC:

PORTRAIT USE:

Regarding Heart Gallery exhibits, are there any areas of the state where the child’s portrait should NOT be displayed, and if so, where:

All Heart Gallery portraits will be used on CYFD’s Heart Gallery website unless otherwise requested here:

BACKGROUND INFORMATION FOR THE PHOTO SHOOT:

Briefly describe the child’s likes, dislikes, special interests, hobbies:

Briefly describe physical or emotional challenges faced by the child of which the photographer should be aware:

State whether there is a preference for a male or female photographer:

NOTES:

Please note any other information you feel is helpful and/or pertinent:

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