Name   Age   Race (for demographic purposes only):

Marital Status Select One Married Single   If Married, Number of Years

Spouse Name Spouse Age Spouse Race (for demographic purposes only)

Street Address/P.O. Box City  State

Zip Code Country

Home Phone Number Work Phone: Ext Fax Number

E-Mail Address   Phone # to best reach you

If you have children at home, how many and what ages?

Number of children at home   Boys Ages Girls Ages

I/We are interested in Adopting/Foster Parenting:

Adopting Foster Parenting 

    Single Child

    Siblings*

    Either

*If interested in Siblings or more than one child, how many children will you accept? 

Gender Preferred: Select One Girl Boy Either

Age Range I/We will accept (check all that apply):

Any Age  1-3 years   4-6 years    7-9 years  10-12 years  13-15 years   16-18 years

I/We will accept children with the following special conditions (check all that apply):

Physical Disabilities    Emotional Disabilities    Mental Disabilities   Learning Disabilities

Would you consider a child that has been sexually abused?  Yes   No

I/We have a current home study with a state agency: Yes No

 If yes, what state and agency

Are you interested in International Adoption?  Yes   No

Comments or Questions I/We have (you may include any parenting experience, experience with children, family strengths, interests, adoption training, additional information you would like on this website, or anything else you want us to know or you want to ask):

I/We wish to be contacted by : Phone   E-Mail    Postal Mail