3580
THE NEW ZEALAND GAZETTE.
[No. 107

12. In the event of the loss or destruction of a license the Secretary for Education shall, before issuing a duplicate license, obtain from the foster-parent a statutory declaration setting forth the facts and circumstances of such loss or destruction.

13. The forms set forth in the Schedule hereto are hereby prescribed as forms to be used for the purposes of the Act and these regulations.

14. The Clerk or Registrar of the Court in which any order of adoption under “The Adoption of Children Act, 1895,” is made shall, immediately upon the issue of the same, forward a true copy thereof to the Secretary for Education, and also to the District Agent of the district wherein the adoptive parent or parents reside, together with a statement setting forth the terms of any agreement or arrangement under which the adoptive parent or parents receive a premium or other consideration in respect of such adoption.

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SCHEDULE.

[Form 1.

“Infant Life Protection Act, 1907” (Section 5).

FORM OF APPLICATION FOR LICENSE AS A FOSTER-PARENT.

The Secretary for Education, Wellington.

I, the undersigned, apply for a license as a foster-parent under “The Infant Life Protection Act, 1907.” I live in the house hereunder described, and I request that such house may be registered as a foster-home for the purposes of the Act.

Name of applicant (in full):

Age:

Occupation:

Married, single, or widow:

If married, husband's name and occupation, and whether he resides at home:

Number of applicant's children { Boys: Ages:
{ Girls: Ages:
at home:

Particulars of any other members of household:

Situation of house:

Number of bedrooms that it contains:

Number of other rooms:

Number of infants it is proposed to receive:

Names and addresses of persons to whom reference can be made as to character:

And I declare that the several particulars above set forth are true and correct.

Dated this __ day of __, 190____.
(Signature of Applicant.)

Witness to signature of applicant:

Occupation:

Address:

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[Form 2.

“Infant Life Protection Act, 1907” (Section 6).

LICENSE OF FOSTER-PARENT.

In pursuance of the provisions of “The Infant Life Protection Act, 1907,” I hereby license __ to receive and maintain in her home, situated at __, not more than __ infants under the age of six years.

This license, unless it is revoked during the period, is in force for one year from the date hereof.

Dated at Wellington, this __ day of __, 190____.
, Secretary for Education.

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[Form 3.

“Infant Life Protection Act, 1907” (Reg. 3).

PARTICULARS AN INFANT RECEIVED INTO A FOSTER-HOME.

Place: __

Date: __

The Secretary for Education, Wellington.

I have received into my licensed home the infant hereunder described, viz.:

Infant's name:

Sex:

Age:

Date of entry into home:

Name of person from whom infant was received:

Occupation:

Address:

Full names, occupations, and addresses of infant's parents or other near relatives, so far as known to foster-parent:

Amount paid or to be paid for infant's maintenance:

By whom maintenance is to be paid:

Remarks:

(Signature of Foster-parent.)

[Form 4.

“Infant Life Protection Act, 1907” (Section 8).

RECORD-BOOK.

(NOTE.—The respective entries must be made immediately after the occurrence of the incidents to be recorded.)

Record of infants received into the foster-home at in charge of

Particulars of Infant's Entry.

Date of entry into home:

Name of infant in full:

Sex:

Age:

Particulars of Infant's Removal.

Date of removal:

Name of person by whom infant was removed:

Occupation:

Address:

Particulars of Infant's Death, if Death occurs.

Date of death:

Cause of death:

Remarks:

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[Form 5.

“Infant Life Protection Act, 1907” (Section 7).

WARRANT REVOKING LICENSE.

By virtue of the provisions of “The Infant Life Protection Act, 1907,” the license dated __, granted to __, is hereby revoked; and I hereby order and direct that the infants hereinafter named now in her home shall be removed therefrom, and provided for as follows:—

Dated at Wellington, this __ day of __, 190____.
, Minister of Education.

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[Form 6.

“Infant Life Protection Act, 1907” (Section 7).

ORDER TO SEND AN INFANT TO AN INDUSTRIAL SCHOOL.

WHEREAS [Name and residence of child], of __, being of the age of __ years and __ months, is an infant within the meaning of “The Infant Life Protection Act, 1907”: And whereas the license under which the infant was maintained in a foster-home under the said Act has been revoked by me, and it appears expedient that the said infant should be admitted to an industrial school:

Now, therefore, I do hereby order and direct that the said infant be forthwith sent to the __ Industrial School, at __, and be there received as an inmate under the provisions of “The Industrial Schools Act, 1882”:

And whereas the said infant belongs, in my opinion, to the [Describe the infant's religious persuasion, creed, or denomination]: I do hereby further order and direct that he shall be brought up and educated in that religion.

Given under my hand, at Wellington, this __ day of __, 190____.
, Minister of Education.

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[Form 7.

“Infant Life Protection Act, 1907” (Section 12).

CONSENT TO THE REMOVAL OF A CHILD.

WHEREAS __ is now an inmate of __, a foster-home within the meaning of “The Infant Life Protection Act, 1907”: And whereas it has been made to appear to my satisfaction that __ is entitled to remove the said __:

I, the undersigned, being a person duly authorised in that behalf, do hereby consent to such removal.

Given under my hand, at Wellington, this __ day of __, 190____.
, Secretary for Education
[or other officer authorised to give consent].

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[Form 8.

“Infant Life Protection Act, 1907” (Section 4).

WARRANT OF EXEMPTION.

In the matter of the application made by __, of __.

In pursuance of the powers conferred upon me by “The Infant Life Protection Act, 1907,” I hereby exempt from the operation of subsection (1) of section 4 of the said Act,

Given under my hand, at Wellington, this __ day of __, 190____.
, Minister of Education.

J. F. ANDREWS,
Acting Clerk of the Executive Council.