ADOPTIVE PARENT APPLICATION

Address

Address

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

Address

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?

Would you accept a Racially Mixed Child?

Would you accept a Black, Hispanic or Asian Child?

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

Address

Address

Address

Address

Address

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Information on Both Adoptive Parents