I, the undersigned ____________ hereby agree to provide for ______________now 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 such as in the judgment of the agen are injurious to the physical, mental or moral well being of the child. The terms and the conditions for the retention of the boy in my family being as follows: To care for him in sickness and in health, to send him to school during the entire free school year until he reaches the age of 16 years; also to have him attend Church and Sunday School 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 preiously dtermined 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. It is understood and agreed on my part that after the period of five years following the date of placement has elapsed, the Society cannot be called upon for removal.I agree to write the Society at least once a year, and should I change my address I will notify the Society.
Recommended by ______________