Privacy Declaration

Waiting Child Access & Privacy Declaration
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
E-mail*
example@example.com
Phone Number
Are you or your spouse (if applicable) a US Citizen?*

YESNO
Do you have a completed, pending, or expired home study?*

YesNo
If you are inquiring about a specific child, please identify or share the child's name:
Do you have an age preference for the child you wish to adopt? *

0-12 months2 years - 3 years3 years to 5 years5 years to 8 years9 years to 12 years12 years to 16 yearsI am unsure at this time
Do you have an age preference for the child you wish to adopt? *
Check all that apply.
Is there a specific country or countries you are interested in adopting a child from? *

ArmeniaBulgariaGeorgiaGhanaGuyanaMorocco (Practicing Sunni Muslim - Only)PakistanSerbiaTrinidad & TobagoUkraineI am biologically related to the child I wish to adoptI do not have a country preference at this timeI wish to adopt domesticallyI wish to adopt from a different country not included in this listI would like home study information for North CarolinaI would like home study information for New York
Is there a specific country or countries you are interested in adopting a child from? *
Check all that apply.
Check to indicate that you or your spouse are a US citizen(s) *If not, we are unable to assist you.*

YesNo
Signature
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Waiting Child Access & Privacy Declaration