Note: The last three chapters are plain text versions of a form I created for this verse. I suggest reading this fic on archiveofourown to view the form correctly. My penname there is also slythatheart.
Form Approved Through 06/30/2020
OMB No. 1204-0003
DoWS Agreement No.
8046
DEPARTMENT OF WERE SERVICES
Same-Sex Family Connection Agreement
Page 2 of 2
CANDIDATE COUPLE A
SECTION 6 – DoWS OFFICIAL USE ONLY
SECTION 6A – MEDICAL APPROVAL
WERE Examination No. OH-M1483W-SC342
Role: Natural father
Passed: [ X ] Yes [ ] No
Date: 05/04/2018
Examined By: N. Bussel MD
HUMANExamination No. OH-M1483H-SC343
Role: Mated father and male donor
Passed: [ X ] Yes [ ] No
Date: 05/04/2018
Examined By: N. Bussel MD
/
SECTION 6B – CONFIRMATION OF COMPLETED PREPATORY THERAPY
Appt. No. OH-F1262H-PST136
Appt. Date: 07/02/2018
Completed: [ X ] Yes [ ] No
Therapist: M.J. Essen LMFT
/
SECTION 6C – CASE-WORKER SIGNOFF
I, Alexandra King, declare that the above registered couple (#OH-M1483) are eligible to enter into a SSF Connection Agreement under existing guidelines. I endorse their application to partner with listed candidates (#OH-F1262).
Signed: A.S. King [OHB3-72]
Date: 07/10/2018
CANDIDATE COUPLE B
SECTION 6 – DoWS OFFICIAL USE ONLY
SECTION 6A – MEDICAL APPROVAL
WERE Examination No. OH-F1262W-EC226
Role: Natural mother
Passed: [ X ] Yes [ ] No
Date: 02/27/2018
Examined By: S. Marsh MD
HUMANExamination No. OH-F1262H-EC227-WV121
Role: Mated mother, donor and surrogate
Passed: [ X ] Yes [ ] No
Date: 02/28/2018
Examined By: S. Andrews MD (OB/GYN)
/
SECTION 6B – CONFIRMATION OF COMPLETED PREPATORY THERAPY
Appt. No. OH-F1262H-PST136
Appt. Date: 07/02/2018
Completed: [ X ] Yes [ ] No
Therapist: M.J. Essen LMFT
/
SECTION 6C – CASE-WORKER SIGNOFF
I, Jennifer Adams, declare that the above registered couple (#OH-F1262) are eligible to enter into a SSF Connection Agreement under existing guidelines. I endorse their application to partner with listed candidates (#OH-M1483).
Signed: Jennifer Adams [OHB5-24]
Date: 07/10/2018
SECTION 6D – DoWS AUTHORITY SIGNOFF
DoWS Authority No. OHH-ACM07
DoWS Authority Name: Martin Shaw
Signature: M. Shaw
Date: 07/21/2018
Result: APPROVED
JOHN Q. PUBLIC - NOTARY PUBLIC - STATE OF OHIO
DoWS Agreement No.
8046