Adoptive Parent Application
Adoptive Applicant #1 Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Date of Birth
*
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Employment Information
Applicant #1
Employer
Job Title
Approx. Annual Income
Do you have health insurance coverage through your employer?
Please Select
Yes
No
If yes, who is it provided through
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Adoptive Applicant #2 Information
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Date of Birth
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Employment Information
Applicant #2
Employer
Job Title
Approx. Annual Income
Do you have health insurance coverage through your employer?
Please Select
Yes
No
If yes, who is it provided through?
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Marital Status
Marital Status
*
Single, Married, Divorced, Domestic Partnership
If married, how long have you been married?
If in a domestic partnership, how long have you been living together?
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Applicant #1 Personal History
Have you ever been admitted to a psychiatric hospital?
Please Select
Yes
No
Have you ever filed for divorce, currently separated, or received an annulment?
Please Select
Yes
No
Have you ever been denied by an adoption agency?
Please Select
Yes
No
Have you ever applied or have been certified as a foster parent in any state?
Please Select
Yes
No
Have you ever received or are currently receiving counseling or therapy services?
Please Select
Yes
No
Please elaborate on all 'yes' answers
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Applicant #2 Personal History
Have you ever been admitted to a psychiatric hospital?
Please Select
Yes
No
Have you ever filed for divorce, currently separated, or received an annulment?
Please Select
Yes
No
Have you ever been denied by an adoption agency?
Please Select
Yes
No
Have you ever applied or have been certified as a foster parent in any state?
Please Select
Yes
No
Have you ever received or are currently receiving counseling or therapy services?
Please Select
Yes
No
Please elaborate on all 'yes' answers
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Have either applicant(s) ever been arrested for any violation of the law? Is yes, please explain:
*
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Household Information
If there are additional people (including children) living in your home, please list below:
Name
First Name
Last Name
Date of Birth
Child of Either Applicants? If yes, please list relationship
Name
First Name
Last Name
Date of Birth
Child of Either Applicants? If yes, please list relationship
Name
First Name
Last Name
Date of Birth
Child of Either Applicants? If yes, please list relationship
Name
First Name
Last Name
Date of Birth
Child of Either Applicants? If yes, please list relationship
If there are additional people in the household, please list below
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References
Three adoption references are needed for your Home Study, please note that only one can be family
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Relationship to Applicant(s)
Relationship to Applicant(s)
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Relationship to Applicant(s)
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Relationship to Applicant(s)
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Adoption Preferences
Please indicate if you are seeking the Infant Program, Foster Program, Home Study Only, or Social Investigative Report
If you are seeking a Social Investigative Report (SIR), please skip the following questions.
Do either applicants practice any religion or hold religious beliefs?
Does either applicant have any cultural, ethnic, or personal preferences for a child?
Please describe your ideal adoption story
Would you prefer an open, semi-open, or closed adoption? Why or why not?
Is there anything you are not willing to accept?
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Submission Page
Signature
*
Name
*
First Name
Last Name
Signature
Name
First Name
Last Name
Submit
Submit
Should be Empty: