Application
Prospective Adoptive Parent 1
*
First Name
Last Name
Prospective Adoptive Parent 2
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Are you needing a new home study, home study update, or post placement services?
*
What is your time frame for wanting services to start?
*
Are you currently working with a child placing agency or an attorney? If yes, who? If no, who do you plan to work with?
*
Please list names and ages of all household members.
*
Applicant One
Please note, that responding "Yes" to any of the below questions does not automatically disqualify you as an adoptive parent. If you answer yes, please explain the circumstance below.
Do you have any criminal history, whether or not you were convicted?
*
No
Yes
Do you have a history, whether or not convicted, of sexual abuse, child abuse or neglect, or family violence as an offender?
*
No
Yes
Do you have a history of alcohol, drug, or substance abuse?
*
No
Yes
Have you ever lost or transferred custody of a child?
*
No
Yes
Have you ever been denied as a foster or adoptive parent?
*
No
Yes
If answered "yes" above, please explain below.
Applicant Two
Please note, that responding "Yes" to any of the below questions does not automatically disqualify you as an adoptive parent. If you answer yes, please explain the circumstance below.
Do you have any criminal history, whether or not you were convicted?
*
No
Yes
Do you have a history of sexual abuse, child abuse or neglect, or family violence as an offender?
*
No
Yes
Do you have a history of alcohol, drug, or substance abuse?
*
No
Yes
Have you ever lost or transferred custody of a child?
*
No
Yes
Have you ever been denied as a foster or adoptive parent?
*
No
Yes
If answered "yes" above, please explain below.
Acknowledgement
Once your application is received and accepted, to move forward with services you will be invoiced $200 for the application fee. We will not be able to move forward with services until the application fee is received. By signing below, you acknowledge and accept the $200 application fee.
Prospective Adoptive Parent 1
Prospective Adoptive Parent 2
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