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Preliminary Application

Preliminary Application

Adoptive Mother

Adoptive Father


Address
Address
Street Address
Street Address Cont.
City
State/Province
Zip/Postal
Do you have an approved home study completed?

Highest Level of Education

Adoptive Mother

Adoptive Father

Employment

Adoptive Mother

Adoptive Father

Information Regarding Children

Adopted?

Adopted?

Adopted?

Adopted?

Adopted?

Marriage

Adoptive Mother

First Marriage?
Have you ever been divorced?

Adoptive Father

First Marriage?
Have you ever been divorced?

Finances

Adoptive Mother

Adoptive Father

Criminal History

Adoptive Mother

Have you ever been arrested or convicted of any crime? Even if the crime has been expunged from your record.

Adoptive Father

Have you ever been arrested or convicted of any crime? Even if the crime has been expunged from your record.

Health

Adoptive Mother

Currently under a physicians care?
Any serious or prolonged illnesses or operations?
Have you ever received treatment for or have any reason to suspect any of the following:
HIV/AIDS?
Heart Disease?
Alcoholism?
Drug Addiction?
Mental Disorder?
Cancer?

Alcohol

Beverages Frequency
Quantity/Occasion

Tobacco

Frequency

Health

Adoptive Father

Currently under a physicians care?
Any serious or prolonged illnesses or operations?
Have you ever received treatment for or have any reason to suspect any of the following:
HIV/AIDS?
Heart Disease?
Alcoholism?
Drug Addiction?
Mental Disorder?
Cancer?

Alcohol

Beverages Frequency
Quantity/Occasion

Tobacco

Frequency

Christian Faith

Views Regarding Adoption

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Statement of Faith