Adoptive Parent Application

Adoptive Applicant #1

Name *

First

Middle

Last

If you’ve gone by other names, please list below.

Date of Birth *

Email *

Phone *

Employment Information

Employer

Job Title

Approx. annual income

Insurance Coverage?

If yes, who is it provided through?

Applicant #2 Information

Name

First

Middle

Last

If you’ve gone by other names, please list below.

Date of Birth

Email

Phone

Employment Information

Employer

Job Title

Approx. annual income

Insurance Coverage?

If yes, who is it provided through?

Marital Status

Marital Status *

single, married, divorced, domestic partnership

If married, for how long?

If in a domestic partnership, for how long?

Applicant #1 Personal History

Have you ever been admitted to a psychiatric hospital *

Have you ever filed for divorce, seperated or received an annulment? *

Have you ever been denied by an adoption agency? *

Have you ever applied or been certified as a foster parent in any state? *

Have you ever been past due on child support? *

Have you ever received or currently receiving counseling or therapy? *

please note, this will in no way disqualify you

Please elaborate on all ‘yes’ answers.

Applicant #2 Personal History

Have you ever been admitted to a psychiatric hospital? *

Have you ever filed for divorce, seperated, or recieved an annulment? *

Have you ever been denied by an adoption agency? *

Have you ever applied or certified as a foster parent in any state? *

Have you ever been past due on child support? *

Have you received or currently receiving therapy or counseling? *

Please elaborate on all ‘yes’ answers.

Have either applicants ever been arrested for any violation of the law (excluding traffic violations)? If yes, please explain

Household Information

If there are additional people living in your home, please list below

Person 1 in Household

First

Middle

Last

Birthdate

Child of Either Applicants? If yes, relationship.

Person 2 in Household

First

Middle

Last

Birthdate

Child of Either Applicants? If yes, relationship.

Person 3 in Household

First

Middle

Last

Birthdate

Child of Either Applicants? If yes, relationship.

Person 4 in Household

First

Middle

Last

Birthdate

Child of Either Applicants? If yes, relationship.

If there are additional people, please list here with Name, Birthdate & Child of Either Applicants? If yes, relationship.

References, please provide at least two

These 3 people listed will be the the 3 that will be needed to write letters of reference. Only one of them can be family.

Reference 1 *

First

Last

Phone *

Email

Relationship

Reference 2 *

First

Last

Phone *

Email

Relationship

Reference 3 *

First

Last

Phone *

Email

Relationship

Adoption Preferences

Please Indicate if you are wanting the Infant Program, Foster Program, Dual Program or home study only

Does either applicant practice any religion or hold any religious beliefs?

Does either applicant have any cultural, ethnic, or personal preferences of a child?

Applicant #1 Adoption Preferences

Please describe your ideal adoption story: *

Would you prefer an open, semi-open, or closed adoption? Why or Why not? *

Is there anything you are not willing to accept? *

Applicant #2 Adoption Preferences

Please describe your ideal adoption story:

Would you prefer an open, semi-open, or closed adoption? Why or Why not?

Is there anything you are not willing to accept?

By signing you understand that failure to provide complete and honest information will result in automatic disqualification from consideration. All information provided will be held in the strictest of confidence.

Applicant #1 Signature *

Date / Time *

Date

Time

Applicant #2 Signature

Date / Time

Date

Time

A Giving Tree Adoptions Inc.