Native American Heritage
Birthparents requesting adoptive placement services through Full Circle Adoptions and Family Building Center, Inc. are advised that Federal Law (Indian Child Welfare Act) requires that adoptive placement of children with Native American Heritage can occur ONLY following specific procedures. Failure to identify and disclose any Native American Heritage in your child could jeopardize the security of your placement. If the proper procedures are not followed, the adoptive placement can be dissolved even years after finalization, leading to disruption in the life of the child and all involved. You are advised to make a vigorous inquiry of your family regarding the existence of Native American heritage. Full Circle Adoptions and Family Building Center, Inc. is aware of the procedures to assist you in pursuing your adoption plan following receipt of this information.
1. Your name: ________________________________________________________________
Other names you’ve used, if applicable: _________________________________________
Your date of birth: __________________________________________________________
Your place of birth: _________________________________________________________
2. Do you think you may have some Native American Heritage? ________________________
If yes, please state for all relatives with Native American Heritage:
Birth Name Married Name Date of Birth Place of Birth Tribe Name
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
B. Are you or any of your relatives enrolled or eligible to be enrolled in any Native American tribe? ____________________________________________________________________
If yes, please state who is enrolled/eligible to be enrolled, the name and location of the tribe. _________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
C. Have you or any of your relatives ever lived on a tribal reservation of other tribal lands? ________ If so, please state the name of the person (including yourself), the dates and places. Please add any information that you think will be helpful to our understanding your relationship to any tribe. _____________________________________________________
__________________________________________________________________________________________________________________________________________________
D. Do you have other significant connections to tribal places and practices? (e.g. Do you visit a reservation? Do you observe tribal customs?) _______________________________ _________________________________________________________________________
E. Please provide as much information as possible about the ancestry of the birth father of this child: _________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
If you are an enrolled member of a Native American
Tribe or your child is likely eligible to be an enrolled member of a tribe, it
is not uncommon for a tribe to wish for the child to be placed first with
members of the family, second with members of your tribe, third with adoptive
parents who have Native American Heritage.
With regard to the first two possibilities, have you inquired of your
immediate family and/or other members of your tribe as to whether or not they
would like to parent your expected child.
Please explain: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________
Thank you for completing this form! Please sign below.
_______________________________ _________________
Name Date