To be on the SEEUS family register, complete this form and mail with annual fee of $20.00 to SEEUS, P.O. Box 1453, Greenville, SC 29602.

The Southeastern Exchange keeps a register of approved families interested in adopting children with special needs. As new children are referred to us, we send registered families information on any children who seem to fit the family's interests, usually three to four weeks before the children appear in our regional photolisting. If a family is interested in a child sent through the register, they simply let us know and we send a referral to the child's agency with a copy of to the family's agency for follow-up. The phone number of the child's caseworker is also given to the family for immediate inquiry as to the status of the child. To be included in our register, complete and return to SEEUS at the above address. (Note: Families may subscribe to the regional photo listing to personally review all children registered with SEEUS. Subscription to this book, SEE US is $50.00 per year).

FORM Below will be fixed soon. Please be patient.

Family Name and Mailing Address Agency having your approved homestudy

________________________________ __________________________________
________________________________ Worker ___________________________
________________________________ _________________________________

Phone: ( ) _____________________ Phone: ( ) ______________________
Yes No
Have you adopted before? ____ ____

Child(ren) you are seeking, or would consider: To help us understand what types of children you feel prepared to parent, please try to describe your range of flexibility.

General types of special needs: Check the Check any of the following characteristics
Level of need you are willing to consider of special needs children which you feel
your family could handle.

                              Mild Moderate Severe
Physical needs ____ ____ ____ _______ weekly therapy
Emotional needs ____ ____ ____ _______ not able to finish high school
Mental Retardation ____ ____ ____ _______ unable to walk/wheelchair
cerebral Palsy ____ ____ ____ _______ poor social skills
Learning Disabled ____ ____ ____ _______ destructive behavior
Delayed Development ____ ____ ____ _______ highly active child
Age range from _____ to _____ years _______ blindness
Sex: Male ___ Female ___ Either ___ _______ bedwetting
Number of siblings: ______ poor speech/communication
2 ___ 3 ___ 4 ___ 5 or more ___ _______ seizures
Race: Black ___ White ___ Biracial ___ _______ sexually active

NOTE ON THE BACK OF PAGE any experience you have with special needs children or any comments which will help us refer children appropriate for you.

Next: Dear Friend Letter