Marital Status click arrow to select Single, never married Married Separated Divorced Widowed

Date of Marriage if applicable (mm/dd/yyyy)

First Parent full name - REQUIRED	Second Parent full name	Address
First Parent gender Male     Female	Second Parent gender Male     Female

City

State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip Code

Daytime Phone

Email address

First Parent Date of Birth (mm/dd/yyyy)	Second Parent Date of Birth (mm/dd/yyyy)
First Parent Income Source Employment Disability SSI Other source of income None	Second Parent Income Source Employment Disability SSI Other source of income None
First Parent Occupation	Second Parent Occupation
First Parent Education Less than High School degree High School Degree or Equivalent Vocational, Trade or Technical School Some College College Degree Post-Graduate Study or Degree	Second Parent Education Less than High School degree High School Degree or Equivalent Vocational, Trade or Technical School Some College College Degree Post-Graduate Study or Degree
First Parent Religion None Buddhist Catholic Hindu Jewish Jehovah's Witness Latter Day Saints Muslim Protestant Other	Second Parent Religion None Buddhist Catholic Hindu Jewish Jehovah's Witness Latter Day Saints Muslim Protestant Other
First Parent Ethnic Origin African-American American Indian Asian Caucasian Hispanic-Latino	Second Parent Ethnic Origin African-American American Indian Asian Caucasian Hispanic-Latino

Number of Children Living at Home: Boys ages ;   Girls ages

Describe your family in general (please limit your comments to 50 words)

Will you adopt a sibling group? Yes     No

Minimum number of children you are willing to adopt 1 2 3 4 5 6 7 8 9

Maximum number of children you are willing to adopt: 1 2 3 4 5 6 7 8 9 10

Minimum age of children you are willing to adopt: Birth 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Maximum age of children you are willing to adopt: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

Gender of children you are willing to adopt: either boy girl

Will You Consider a Child Who Has Previously Been in Adoptive Placement?: Yes    No

Ethnic Preference - Check all that apply

Any        African-American        American Indian        Asian        Caucasian        Hispanic-Latino

Definitions with **NAE are courtesy of the National Adoption Exchange

Risk factors in Child's Background you are NOT willing to accept (Check all that apply)

HIV exposed       History of abuse or neglect       History of multiple placements Lead Poisoning        Mental Illness in birth family        Mental Retardation in the birth family Premature birth        Schizophrenia in birth family        Sexual Abuse

Emotional/Mental Conditions you are NOT willing to accept (Check all that apply)

Anorexia       Assaultive Behavior       Attachment Disorder Attention Deficit Disorder       Autism       Behavior Problems       Bipolar disorder        Depression        Developmental Disabilities        Emotionally Disturbed        Enuresis/ Encopresis        Fetal Alcohol Syndrome        Fire Setting History        History of Animal Cruelty        Hyperactivity        Learning Disabilities        Mental Retardation        Obsessive compulsive disorder        Oppositional defiant disorder        Post traumatic stress disorder        Psychosis        Runaway        Schizophrenia        Self Abuse        Sexually Acting Out        Takes psychiatric medication

Physical/Medical Conditions you are NOT willing to accept (Check all that apply)

AIDS/HIV positive       Alcohol Abuse       Allergies       Amputee       Anemia/blood disorder       Asthma Disorder       Attention Deficit       Autism       Blindness, correctable       Blindness, will never have sight       Cerebral palsy       Cystic Fibrosis       Developmental Disabilities       Down Syndrome       Drug Abuse       Enuresis/ Encopresis       Fetal Alcohol Syndrome       Growth Disorders       Hearing Loss Partial       Hearing Loss Profound       Hyperactivity       Infant Alcohol Addiction/Prenatal Exposure       Infant Drug Addiction/Prenatal Exposure       Learning Disabilities       Mental Retardation       Neurological impairment       Paralysis - partial paraplegic       Paralysis - quadriplegic       Seizure Disorder       Speech Disorder       Spina Bifida       Terminal Illness       Tourette Syndrome       Wheelchair Dependent

Degree of Overall Disability you are willing to accept: none Mild Moderate Severe

Describe your family's special skills and experience related to children with disabilities:
Please limit your comments to 50 words.

Pets in household (Please list all pets)

Date last homestudy was completed (mm/dd/yyyy)

ALL AGENCY INFORMATION IS REQUIRED TO SUBMIT THIS FORM

Social Worker Name

Agency Name

Street/Mailing Address

City

Agency State AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Zip Code

Agency Phone

Worker's Phone & Extension