ADOPTIVE PARENT APPLICATION
Preliminary Information
Referred by:
Adoptive Parent (1)
First Name
Last Name
Maiden Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Own or Rent
Own
Rent
How Long have you lived here?
Birthplace
Age
Social Security Number
Drivers License Number
State
Physical Description: Height and Weight
Eye Color
Hair Color
Race
Marriage Date
-
Month
-
Day
Year
Date
Religion
Nationality
Highest Grade Completed
Special Interests or Talents
Military Service
Yes
No
Occupation
Employer
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Approximate Annual Income $
Have you ever been arrested or convicted of a Crime other than Minor Traffic Violations?
Yes
No
If YES, please explain:
Do you drink Alcohol?
Yes
No
Do you use nicotine?
Yes- Cigarettes
No- Cigarettes
Yes-Other
No-Other
Any serious or chronic illness including mental or psychiatric treatment?
Yes
No
If YES, please explain
Adoptive Parent (2)
First Name
Last Name
Maiden Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Own or Rent
Own
Rent
How Long have you lived here?
Birthplace
Age
Social Security Number
Drivers License Number
State
Physical Description: Height and Weight
Eye Color
Hair Color
Race
Marriage Date
-
Month
-
Day
Year
Date
Religion
Nationality
Highest Grade Completed
Special Interests or Talents
Military Service
Yes
No
Occupation
Employer
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Approximate Annual Income $
Have you ever been arrested or convicted of a Crime other than Minor Traffic Violations?
Yes
No
If YES, please explain:
Do you drink Alcohol?
Yes
No
Do you use nicotine?
Yes- Cigarettes
No- Cigarettes
Yes-Other
No-Other
Any serious or chronic illness including mental or psychiatric treatment?
Yes
No
If YES, please explain
Information on Both Adoptive Parents
Has your infertility been diagnosed?
Yes
No
If YES, please tell us the reason
Have you applied to other adoption agencies/attorneys, and where?
Would you accept a Special Needs Child?
Yes
No
Mild Physical Handicap
Moderate Physical Handicap
Severe Physical Handicap
Mild Mental Handicap
Moderate Mental Handicap
Severe Mental Handicap
Would you accept a Racially Mixed Child?
Yes
No
Black/White
Hispanic/White
Asian/White
Would you accept a Black, Hispanic or Asian Child?
Yes
No
Black
Hispanic
Asian
Would you accept an older child?
Yes
No
Up to what age?
Would you accept a Sibling Group?
Yes
No
What ages?
Other Comments
Adoptive Parent (1): How long have you been interested in adoption and why do you want to adopt?
Adoptive Parent (1): How do you feel about your spouse as a parent?
Adoptive Parent (2): How long have you been interested in adoption and why do you want to adopt?
Adoptive Parent (2): How do you feel about your spouse as a parent?
***PLEASE ATTACH SOME RECENT FAMILY PHOTOGRAPHS***
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REFERENCES
Please supply 6 references, one of which may be related. Additionally, please supply a name of someone we may contact at your place of employment with respect to a reference. ALL APPLICATIONS MUST BE COMPLETE WITH ZIP CODES OR APPLICATION WILL NOT BE PROCESSED. All references will be contacted by mail and advised of the prospective adoption and requested to provide a written response to our office.
1. Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
2. Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
3. Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
4. Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
5. Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
6. Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Signature- Adoptive Parent (1)
Clear
Signature- Adoptive Parent (2)
Clear
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