Adoption Center Media Recruitment Request

Media Recruitment Form

This Media Recruitment Form is to ensure that the Adoption Center has all the necessary information to proficiently recruit for your youth. It will remain valid for one year upon submission. Please complete and sign. Adoption Center staff will contact you regarding scheduling.
Name*

Youth's First NameMiddle NameLast Name
Youth's Alias
only if needed
Youth's Pronouns
Youth's Gender*
Youth's Race/Ethnicity*
Youth's Date of Birth*

MonthDayYear
Date
State of Jurisdiction*
County of Jurisdiction
PAE ID#*
If used
Social Worker Completing Form*

Your First NameYour Last Name
Your Office Phone Number
Please enter a valid phone number.
Your Cell Phone Number
Please enter a valid phone number.
Your Email Address*
example@youragency.org
Your Organization
Organization's Name
Youth's Legal Status*
Youth's Primary Language
Youth's Grade Level
Youth's Current Placement Setting
Is the Youth exploring any families right now in any capacity?

YesNo
Note:

If the Youth starts exploring connections with families in any way it is your responsibility to inform the coordinator, Jennifer Mitchell, cell 619-806-7059 or jmitchell@adopt.org.
Please answer the following questions to help us learn more about the youth from a strength-based perspective.
Personality: What sticks out about them? Are they an introvert or an extrovert? What makes them happiest? What do they love to do? What would their “dream day” look like? What would they like to be when grown up?*
School: Grade, favorite subjects, special supports needed, educational & career goals, honors received, etc. *
Hobbies: What are the youth’s favorite things? Sports, video games, music movies, weekend activities, etc. What do they like to do in their spare time?*
Family: What is the ideal family? How does the youth feel about adoption? What kind of family would the child like to have? Are there any restrictions for the placement of this child? Do they need to be the only child or the youngest child in the home?Single-parents? Same-sex couples? Pets, okay?*
Dreams & Wishes: If the youth had 3 wishes, what would they be? (I am happiest when?) *
Your Insight: What is your favorite thing to do with this youth? Do you have a fun story? Give us at least one quote about the youth.*
Other Notes: Anything else that will help us create the best environment for the youth?
Recruitment Opportunities

Please check YES or NO next to thevarious media recruitment opportunities offered by the Adoption Center
NBC10 – Wednesday’s Child (television & online):*

YesNo
- Aired weekly during 11am newscast and posted to www.nbcphiladelphia.com.
- Worker must be able to transport or arrange transport for themselves and the youth to the taping location (taping location is based on the child’s interests).
- The tapings usually take place Tuesday Mornings from 10:30AM – 12:00 PM.
What would be the child's ideal activity for the NBC10 taping? Please list a few ideas. For older youth "future planning" type venues tend to get more inquiries, i.e. college or trade school visits.
KYW News Radio – Wednesday’s Child (radio & online):*

YesNo
- Profiles air on Wednesdays (6 times throughout the day) and are posted on www.kyw1060.com
- Tapings are held on Zoom.
Philadelphia Inquirer – Monday’s Child (print):*

YesNo
- Runs weekly.
- Worker MUST submit the youth’s photo and narrative with the submission of this form.
Philadelphia Tribune – Monday’s Child (print):*

YesNo
- Runs weekly.
- Open to African American/Black and Latinx children only.
- Worker MUST submit the youth’s photo and narrative with the submission of this form.
Meet Our Children – Adoption Center (online photo listing page):*

YesNo
Who should receive inquiries from home studied families?

First NameLast Name
Email
example@example.com
Adoption Center Newsletter – Child Highlight (digital):*

YesNo
- Runs weekly and sent to families in the Adoption Center's network.
- Worker MUST submit the youth’s photo and narrative with the submission of this form.
WQBR’s The BEAR - Good News Magazine (print & online):*

YesNo
- Each month, the profiles of 3 children are featured in Good News at www.bear999.com and in the WQBR (a radio station serving the Susquehanna Valley) print publication.
- Worker MUST submit the youth’s photo and narrative with the submission of this form.
Parenting Special Needs Magazine (online):*

YesNo
- Each issue features the profiles of 2 children; new issues are published every other month.
- Worker MUST submit the youth’s photo and narrative with the submission of this form.
Reewind Network (online):*

YesNo
- Radio, television and print features available monthly.
Anchor Project (in person):*

YesNoPossibly, send me more information
A community-based mentorship program for youth in care ages 12 and up, connecting youth in foster care with responsible adult mentors.
Worker MUST send the youth’s photo and narrative with the submission of this form. Use a photograph that clearly shows the youth's face.
Youth Photo Upload*

Upload a clear photo showing youth's face
Cancelof
Release and Authorization to Photograph/Videotape

The undersigned does hereby consent to photographing and/or videorecording of the child listed below. I understand that the images may be used in print publications, online publications, presentations, websites, and social media.

The undersigned does hereby release the Adoption Center from all claims whatsoever arising out of, related to or based on the use of said materials.
Social Worker Name

First NameLast Name
Child Name (if signing)

First NameLast Name
Social Worker Signature*

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Child Signature

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Media Recruitment Form

Note:

Please answer the following questions to help us learn more about the youth from a strength-based perspective.

Recruitment Opportunities

Release and Authorization to Photograph/Videotape