Child or Staff Departure and Notification
Country Directors: please submit this form within 1 week of a child’s departure, or suspected departure, from Asia’s Hope’s care. Submit the completed form via email to jeremiah@asiashope.org or to the Asia’s Hope Program Director in the Executive Office. You will receive confirmation that your submission was received within 24 hours. If you do not receive confirmation within that time period, contact the Executive Office immediately.
Name of person completing this assessment
*
First Name
Last Name
Position/title:
*
Your email:
*
example@example.com
Your phone number
*
-
Country Code
-
Area Code
Phone Number
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Child or Staff Information
Basic information
Full legal name
*
First Name
Middle Name
Last Name
Other names or nicknames
Asia's Hope Home Name
*
Date of birth
*
-
Month
-
Day
Year
Date
Sex
*
Male
Female
Other
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Departure Information
Current information and whereabouts of the child or staff
Date the child or staff departure
*
-
Month
-
Day
Year
Date
Reason for departure
*
Do you think this departure will be temporary?
*
Yes
No
If "yes" please explain. And what conditions or terms of you set for their return?
Current whereabouts of the child or staff
*
Current address
Street Address
Street Address Line 2 or Landmark
City
State / Province
Postal / Zip Code
With whom is the child currently living (caregiver)?
Contact information and address of current caregivers
Address, phone, email
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Sign and submit
You will receive confirmation from the Executive Office that your submission was received within 24 hours. If you do not receive confirmation within that time period, please contact the Executive Office immediately.
Who provided information to you about this child's departure?
*
Do you have any concerns or questions about the accuracy of the information you were given about this child? If yes, please describe.
*
To the best of my knowledge, I certify that the contents of this form are true and accurate.
Date signed
*
-
Month
-
Day
Year
Date
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