(Placing –Out Department)
hereby agree to provide for _______________________________________________________________
now of the age of ____________________________ years, until the said boy shall reach the age of 18
years, according to the following terms and conditions, and with the full understanding that the
Society reserves the right to remove the child previous to legal adoption if at any time the
circumstances of the home become such as in the judgment of the agent are injurious to the
physical, mental or moral well-being of the child.
The terms and conditions for the retention of the boy in my family being as follows: To care for him
in sickness and health, to send him to school during the entire free school year until he reaches
the age of 14 years, and thereafter during the winter months at least, until he reaches the age of 16
years; also to have him attend Church and Sunday School when convenient, and to retain him as a
member of my family until he reaches the age of 17 years, and thereafter for the final year, until he
is 18 years old, to pay the boy monthly wages in addition to his maintenance, the amount thereof to
be previously determined after consultation with the Society’s local agent and his approval. In
case he proves unsatisfactory, I agree to notify the society and pending his removal, to keep him a
reasonable length of time after such notice has been given. I agree, moreover, to use my best
endeavor then and at all times, to detain him, should he try to leave me, until the Society can take
steps for his removal. I agree to keep him at all times as well supplied with clothing as he was when
I received him.
I agree to write to the Society at least once a year, and should I change my address I will notify
the Society.
__________________________________
Witness, ___________________________________
___________________________________
Date, ______________________________________
HAVE THIS NOTICE AND RECEIPT IN YOUR HAND WHEN TRAIN ARRIVES