I, or (we) ________________; residence is (are) ______________________hereby request that my or (our) child(ren) (state names of child(ren) ____,___________________,_______________,_____________

for the purpose of raising my (our) child(ren) in an appropriate, loving, stable, and moral family request and desire my (our ) child(ren) be adopted and or have a guardianship placed over them in the event of my (our) death that qualifies as a Caucasian Christian, heterosexual. It is my (our) intent, desire, and wishes that my (our) child(ren) never be placed in the home or under the guardianship whether temporary or permanent of any individual or group of individuals who are not Caucasian, Christian, and heterosexual.