Preliminary Application
WE'RE HERE FOR YOU
Are you interested in Domestic or International Adoption?
*
Domestic
International
Do you have an approved home study completed?
*
Yes
No
If yes, please upload your home study:
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Your Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Marriage
*
Location of Marriage
*
Denomination of Faith
*
Name of Church
*
Do you attend church regularly? If no, please explain.
*
Why do you wish to adopt?
*
Do you have a preference as to sex, nationality, or physical characteristics?
*
Would you consider a child of another race or ethnic group? Please be specific.
*
Would you consider a physically or mentally challenged child?
*
Would you consider twins or a sibling group? Describe situations you are willing to consider.
*
Preferences regarding the age range of the child. Be specific:
*
Describe the degree of openness you are comfortable with with meeting, talking with, and possible long-term face-to-face visits with the birthmother.
*
Adoptive Mother
Name
*
First Name
Last Name
Cell Phone
*
Please enter a valid phone number.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Race
*
Highest Level of Education:
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High School
Bachelor's Degree
Master's Degree
Doctorate
Name of School:
*
Location of School
*
Year Graduated:
*
Occupation/Title:
*
Employer:
*
Length of Employment:
*
Have you ever been divorced?
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Yes
No
Yearly Gross Salary
*
Other Sources of Income/Amount
*
Have you ever been arrested or convicted of any crime? Even if the crime has been expunged from your record.
*
Yes
No
Health Status
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Any physical limitations?
*
Are you currently under a physician's care?
*
Yes
No
Do you have any serious or prolonged illnesses or operations?
*
Yes
No
List all prescription medications and diagnosis
*
Do you have HIV/AIDS?
*
Yes
No
Heart Disease?
*
Yes
No
Drug Addiction?
*
Yes
No
Metal Disorder?
*
Yes
No
Cancer?
*
Yes
No
Do you have any mental health diagnoses? If yes, please list:
*
Alcohol Beverage Frequency
*
Never
Occasionally
Often
Daily
Quantity per Occasion
*
None
1-2
3-4
5 or more
Tobacco Use Frequency
*
Never
Occasionally
Often
Daily
Smoker quantity/daily # of packs
*
Chewing or dipping daily quantity
*
Adoptive Father
Name
*
First Name
Last Name
Cell Phone
*
Please enter a valid phone number.
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Age
*
Race
*
Highest Level of Education:
*
High School
Bachelor's Degree
Master's Degree
Doctorate
Name of School:
*
Location of School
*
Year Graduated:
*
Occupation/Title:
*
Employer:
*
Length of Employment:
*
Have you ever been divorced?
*
Yes
No
Yearly Gross Salary
*
Other Sources of Income/Amount
*
Have you ever been arrested or convicted of any crime? Even if the crime has been expunged from your record.
*
Yes
No
Health Status
*
Any physical limitations?
*
Are you currently under a physician's care?
*
Yes
No
Do you have any serious or prolonged illnesses or operations?
*
Yes
No
List all prescription medications and diagnosis
*
Do you have HIV/AIDS?
*
Yes
No
Heart Disease?
*
Yes
No
Drug Addiction?
*
Yes
No
Metal Disorder?
*
Yes
No
Cancer?
*
Yes
No
Do you have any mental health diagnoses? If yes, please list:
*
Alcohol Beverage Frequency
*
Never
Occasionally
Often
Daily
Quantity per Occasion
*
None
1-2
3-4
5 or more
Tobacco Use Frequency
*
Never
Occasionally
Often
Daily
Smoker quantity/daily # of packs
*
Chewing or dipping daily quantity
*
Children
Child's Name
First Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
Age
Adopted?
Yes
No
Child's Name
First Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
Age
Adopted?
Yes
No
Child's Name
First Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
Age
Adopted?
Yes
No
Child's Name
First Name
Last Name
Birthdate
-
Month
-
Day
Year
Date
Age
Adopted?
Yes
No
Family Photo
*
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Adoptive Mother's Signature
*
Signature Date
*
Adoptive Father Signature
*
Signature Date
*
Statement of Faith
*
I have read and agree with the agency's statement of faith
Statement of Faith
Submit
Should be Empty: