Orientation Registration & Child Inquiry Form
Which Heart Gallery AK child(ren) are you inquiring about?
*
Non-child specific inquiry
Alyssa
Ava
Brooklynn
Blake
Carmen
David
Lilli
Terry
Landen
Matrona
Yashira
James *needs to remain in Alaska
Dominic *needs to remain in Alaska
Willow *needs to remain in Alaska
Aiden *needs to remain in Alaska
Mel_Ser_Chris *needs to remain in Alaska
Where are you located?
*
Alaska
Not Alaska
Which Region on the above map are you located in?
*
Anchorage Region
Northern Region
Southcentral Region
Southeast Region
What town/village are you in?
*
i.e. Kotzebue
Your Name
*
First Name
Last Name
Your Email
*
example@example.com
Your Phone Number
*
-
Area Code
Phone Number
Your Gender Identity
*
Male
Female
Your Ethnicity
*
Alaska Native/American Indian
Asian/Pacific Islander
Black
Hispanic/Latinx
White
Undeclared/Other
Is this a two-parent household?
*
Yes
No
Is there a stay-at-home parent in your family?
*
Yes
No
Second Parent Name
*
First Name
Last Name
Second Parent Email
*
example@example.com
Second Parent Phone Number
*
-
Area Code
Phone Number
Second Parent Gender Identity
*
Male
Female
Second Parent Ethnicity
*
Alaska Native/American Indian
Asian/Pacific Islander
Black
Hispanic/Latinx
White
Undeclared/Other
Do you have pets/livestock?
*
Yes
No
Please elaborate on what pets/livestock you have:
*
Does anyone else live in your home besides yourself and any partner you've already identified?
*
Yes
No
Who else lives in your home?
*
Are you currently licensed for foster care in your state?
*
Yes
No
No, but previously licensed
Do you have a current positive home study?
*
Yes
No
Do you have any adoption specific training?
*
Yes
No
Please specify your adoption specific training.
*
Have you completed a Heart Gallery of Alaska orientation session?
*
Yes
No
Would you like to register for the next Heart Gallery Orientation?
*
Yes
No
Please note that our orientation is the 1st step in the matching process
& is required of all families wishing to adopt from The Heart Gallery
Date completed:
*
-
Month
-
Day
Year
Date
Which orientation session would you like to register for?
*
Saturday, February 11th 10AM-12PM
Saturday, March 11th 10AM-12PM
Saturday, April 8th 10AM-12PM
Saturday, May 13th 10AM-12PM
Do you have any professional/personal experience with at risk youth, people w/disabilities, adoption, mental health, foster care etc?
*
Yes
No
Please elaborate on your experience
*
What is the date of your most recent home study?
*
-
Month
-
Day
Year
Date
In which state are you licensed for foster care?
Who lives in your home? (Please include relationship, age, and gender)
*
Date of Birth
-
Month
-
Day
Year
Date
Please select any of the following strengths that describe your family:
We are equipped and/or willing to become equipped to parent youth...
*
with a history of significant medical needs
who are experiencing educational challenges
with Autism Spectrum Disorder
who need support in staying connected to their Alaskan Native heritage
who engage in sexual behavior/language that is not socially appropriate
with sexual behaviors harmful to others
with a history of residential treatment
who identify as LGBTQIA+
with Reactive Attachment Disorder
with self-harming behaviors
with property damaging behaviors
who experienced prenatal drug exposure
who need special care related to toileting
with Fetal Alcohol Syndrome Disorder
with violent behaviors towards younger children
with violent behaviors towards animals
with Attention Deficit Hyperactivity Disorder
who may not achieve full independence as an adult
who are affected by exposure to Sexism/Racism/Homophobia
who have a history of making false accusations
Is there anything else we should know about your family?
Submit
Should be Empty: