COAC Membership Questionnaire

COAC Membership Questionnaire
1st Parent's Name

First NameLast Name
2nd Parent's Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
Would you like to participate in an in person adoptive parent group?

YesNoMaybe, please keep me informed of your group's activities
If no, why?
Are you a(n) (please mark all that apply):

Adoptive parentFoster parentKinship parentProspective adoptive parent
If applicable, how long have you been an adoptive parent?
Mark all that describe your family

Single adoptive parentFamily with multiple adoptoinsFamily with biological and adoptive childrenTransracial adoptive familyLGBTQ adoptive family
Please tell us if you have adopted (mark all that apply):

A sibling groupAn older child/childrenA physically disabled child/childrenAn emotionally injured child/childrenAn internationally adopted child/childrenAn infant/infantsA relative's or friend's child/childrenA child/children of a different race or ethnicityA child with intellectual developmental delays
Please list the ages and gender of your child/children:
Please select the topics you are most likely to discuss with other parents:

Strengthening parent-child relationshipsBehavior of childrenAdolescent needs and behaviorReactions of family and friends about adoptionAge-appropriate child developmentAddressing child's questions about adoption/birth familySexual acting outAnger/destructivenessSchool related challengesMaking changes in state adoption lawsAddressing legal issues related to adoptionAdoption assistance/adoption subsidiesPost-Adoption ServicesSpecial needsAllegations
If a group in your area is created, how often would you like to meet?

Once a monthEvery other monthOnce a quarter
What is the best time for you to meet?

Day timeEarly Evening between 4:30-7:30 PMLate Evening between 7:30-9:30 PMSaturday MorningsSaturday AfternoonsSunday AfternoonsSunday Evenings
If a parent group were formed, would you be willing to help:

with refreshmentsproviding transportation for another parentmaking telephone callsprepare mailingsgreet newcomers and make them feel welcomeprepare the room before and after the meetingplan group meetings/activitiesfind child care
What special skills do you have to offer a group of this nature? (Are you skilled at word processing, graphic design, accounting, training, writting, fundraising, bargan shipping, etc.?)
I give permission for my/our name(s), address, email, and phone number to be shared with the parent group leaders for the purpose of contacting me about future activities.
Date
Signature
1 Year Membership $10.00

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