Which Adoption Orientation are you registering to attend?
Wednesday, October 15th, 5PM-6:30PM
Wednesday, November 5th, 5PM-6:30PM
Saturday, December 13th, 10AM-12PM
This inquiry is about:
*
Questions/Orientation
Brooklynn
Blake
Carmen
David
Lilli
Yashira
Jorden
Dominic
Aiden
William
Lorie
Tanesha
Where are you located?
*
Alaska
Out of State
ignore this field it is no longer in use - Which Region 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
Other
Your Ethnicity
*
Alaska Native/American Indian
Asian/Pacific Islander
Black
Hispanic/Latinx
White
Other
Is this a two-parent household?
*
Yes
No
Is there currently 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
Other
Second Parent Ethnicity
*
Alaska Native/American Indian
Asian/Pacific Islander
Black
Hispanic/Latinx
White
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 currently lives in your home?
*
Ignore this field it is no longer in use - Who else lives in your home?
Ignore this field it is no longer in use - Who lives in your home? (Please include relationship, age, and gender)
Are you currently licensed for foster care in your state?
*
Yes
No
No, but previously licensed
Do you have a current positive non-child specific 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 Adoption & Permanency Orientation?
*
Yes
No
*Orientation is required as it is the 1st step in adopting from the Heart Gallery
Date completed:
*
-
Month
-
Day
Year
Date
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
*
Please select which of the following statements are true of your family:
We are equipped and/or willing to become equipped to parent youth...
*
who need a stay at home parent
who need to be an only child
who need to be the youngest
who need support with birth family contact
who need support with sibling contact
who experience educational challenges
with violent behaviors that put the safety of others in danger
with Autism Spectrum Disorder
with self-harming behaviors
who need support in staying connected to their Alaskan Native heritage
with sexual behaviors that put the safety of others in danger
with sexual behaviors that put the safety of themselves in danger
who engage in sexual behavior/language that is not socially appropriate
who are affected by exposure to Sexism/Racism/Homophobia
who may not achieve full independence as an adult
who identify as LGBTQIA+
with property damaging behaviors
with a history of residential treatment
who experienced prenatal drug exposure
with Reactive Attachment Disorder
who need special care related to toileting
with Fetal Alcohol Syndrome Disorder
who don't get along with their peers of same gender
who can't live in a home with peers of the opposite gender
who don't get along with their peers regardless of gender
who have a history of bullying
who have a criminal record
with Attention Deficit Hyperactivity Disorder
who have a history of making false accusations
whose level of independence does not match their chronological age
who experience tantrums
Is there anything else we should know about your family?
Submit
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