Adoption Rally Application

Full Name

First NameLast Name
E-mail
Spouse's First Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone

Area CodePhone Number
Mobile Phone

Area CodePhone Number
Date of Birth

DayMonthYear
Number of dependent children in your immediate family?
Names and ages of your biological children:
Have you adopted before?
Please confirm you are adopting through an official 501(c)(3) placement agency?
Date home study was satisfactorily completed?

MonthDayYear
NCAA Compliance Questions
Do you have children or foster children in grades 7-12?
Do you or any family member coach a middle or high school basketball team?
Does anyone in your family have children in grades 7-12 that play middle or high school basketball?
Do you have relationship that you would define as more than a "casual acquaintance" with anyone in grades 7-12 that plays middle or high school basketball?
Employment
Please list emplyment information for the primary source of income
Name of Employer
Position
Work Phone
Spouse's Occupation
Does your organization have adoption benefits?
Church Information
Church Name
Church Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Church Phone

Area CodePhone Number
Church Web Site
Minister's Name
Adoption Rally Plans
The success of an adoption rally is based on how many people you can drive to a Lipscomb basketball game. When completing the questions below, please use as much detail as possible. The answers below are the primary factor in determining adoption rally grant recipients.
How do you plan on driving attendance to your assigned Lipscomb basketball game?
What groups are you a part of that will support your rally?
How many people do you think you can realistically convince to attend your rally?
Adoption Cost
What is your estimated total adoption expense?
What is the current remaining balance on your total adoption expenses?
What is the total amount of funds you have raised or have been pledged so far for your adoption?
What is the total amount of the personal funds you are committing to your adoption?
Comments/Special financial circumstances to be considered (if you need more room, please attach a note to your supporting documents when you send them in and indicate here that you will do so)
Adoption Placement Agency Information
Adoption Placement Agency Name
(Not the home study agency, unless they are one in the same)
Agency Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Agency Phone

Area CodePhone Number
Caseworker's Name
Caseworker's business phone

Area CodePhone Number
Caseworker's email address
Adoptee Information
We realize that you may not yet have answers to the following questions. If you do not yet know an answer, simply leave the field blank--this will not impact your application.
Adoptee's Country of Origin
How many children are you in the process to adopt?
Do you have a referral yet?
Adoptee's Name
Adoptee's Age
Names and ages of other children being adopted if multiple(e.g. Jimmy 3 months, Sarah 5)
Expected Placement Date

MonthDayYear
Should be Empty:

NCAA Compliance Questions

Employment

Church Information

Adoption Rally Plans

Adoption Cost

Adoption Placement Agency Information

Adoptee Information