Heart Gallery Website Inquiry

Orientation Registration & Child Inquiry Form
Which Heart Gallery AK child(ren) are you inquiring about?*

Non-child specific inquiryAlyssaAvaBrooklynnBlakeCarmenDavidLilliTerryLandenMatronaYashiraJames *needs to remain in AlaskaDominic *needs to remain in AlaskaWillow *needs to remain in AlaskaAiden *needs to remain in AlaskaMel_Ser_Chris *needs to remain in Alaska
Where are you located?*

AlaskaNot Alaska
Which Region on the above map are you located in?*

Anchorage RegionNorthern RegionSouthcentral RegionSoutheast Region
What town/village are you in? *
i.e. Kotzebue
Your Name*

First NameLast Name
Your Email*
example@example.com
Your Phone Number*

Area CodePhone Number
Your Gender Identity*

MaleFemale
Your Ethnicity*

Alaska Native/American IndianAsian/Pacific IslanderBlackHispanic/LatinxWhiteUndeclared/Other
Is this a two-parent household?*

YesNo
Is there a stay-at-home parent in your family?*

YesNo
Second Parent Name*

First NameLast Name
Second Parent Email*
example@example.com
Second Parent Phone Number*

Area CodePhone Number
Second Parent Gender Identity*

MaleFemale
Second Parent Ethnicity*

Alaska Native/American IndianAsian/Pacific IslanderBlackHispanic/LatinxWhiteUndeclared/Other
Do you have pets/livestock?*

YesNo
Please elaborate on what pets/livestock you have:*
Does anyone else live in your home besides yourself and any partner you've already identified?*

YesNo
Who else lives in your home? *
Are you currently licensed for foster care in your state?*

YesNoNo, but previously licensed
Do you have a current positive home study?*

YesNo
Do you have any adoption specific training?*

YesNo
Please specify your adoption specific training. *
Have you completed a Heart Gallery of Alaska orientation session?*

YesNo
Would you like to register for the next Heart Gallery Orientation?*

YesNo
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:*

MonthDayYear
Date
Which orientation session would you like to register for?*

Saturday, February 11th 10AM-12PMSaturday, March 11th 10AM-12PMSaturday, April 8th 10AM-12PMSaturday, May 13th 10AM-12PM
Do you have any professional/personal experience with at risk youth, people w/disabilities, adoption, mental health, foster care etc?*

YesNo
Please elaborate on your experience*
What is the date of your most recent home study? *

MonthDayYear
Date
In which state are you licensed for foster care?
Who lives in your home? (Please include relationship, age, and gender)*
Date of Birth

MonthDayYear
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 needswho are experiencing educational challengeswith Autism Spectrum Disorderwho need support in staying connected to their Alaskan Native heritagewho engage in sexual behavior/language that is not socially appropriatewith sexual behaviors harmful to otherswith a history of residential treatmentwho identify as LGBTQIA+with Reactive Attachment Disorderwith self-harming behaviorswith property damaging behaviorswho experienced prenatal drug exposurewho need special care related to toiletingwith Fetal Alcohol Syndrome Disorderwith violent behaviors towards younger childrenwith violent behaviors towards animalswith Attention Deficit Hyperactivity Disorderwho may not achieve full independence as an adultwho are affected by exposure to Sexism/Racism/Homophobiawho have a history of making false accusations
Is there anything else we should know about your family?
Should be Empty:

Orientation Registration & Child Inquiry Form

Please note that our orientation is the 1st step in the matching process

Please select any of the following strengths that describe your family: