Preliminary Application Preliminary Application Please confirm you have read and understand the New Beginnings Statement of Faith * Please indicate if you’re interested in Domestic or International Adoption * Adoptive Mother First Name * Middle Name * Last Name * Cell Phone * Work Phone * Email * Date of Birth * Age * Race * Adoptive Father First Name * Middle Name * Last Name * Cell Phone * Work Phone * Email * Date of Birth * Age * Race * Home Phone * Fax Number * Address * Address Street Address Street Address Street Address Cont. Street Address Cont. City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Do you have an approved home study completed? * Yes No When does it expire? * What agency completed it? * Highest Level of Education Adoptive Mother Name of School * Location of School * Year Graduated * Degree Earned * Adoptive Father Name of School * Location of School * Year Graduated * Degree Earned * Employment Adoptive Mother Occupation / Title * Employer * Length of Employment * Adoptive Father Occupation / Title * Employer * Length of Employment * Information Regarding Children Name Birthdate Age Adopted? Yes No Provide the date of adoption Name Birthdate Age Adopted? Yes No Provide the date of adoption Name Birthdate Age Adopted? Yes No Provide the date of adoption Name Birthdate Age Adopted? Yes No Provide the date of adoption Name Birthdate Age Adopted? Yes No Provide the date of adoption Marriage Date of Marriage * Location * Adoptive Mother First Marriage? * Yes No Have you ever been divorced? * Yes No Adoptive Father First Marriage? * Yes No Have you ever been divorced? * Yes No Finances Adoptive Mother Yearly Gross Salary * Other Sources of Income/Amount * Adoptive Father Yearly Gross Salary * Other Sources of Income/Amount * Criminal History Adoptive Mother Have you ever been arrested or convicted of any crime? Even if the crime has been expunged from your record. * Yes No Please list the date and nature of each: * Adoptive Father Have you ever been arrested or convicted of any crime? Even if the crime has been expunged from your record. * Yes No Please list the date and nature of each: * Health Adoptive Mother Health Status * Physical Limitations * Currently under a physicians care? * Yes No Please explain: * Any serious or prolonged illnesses or operations? * Yes No Please explain: * List all prescription medications and diagnosis: * Have you ever received treatment for or have any reason to suspect any of the following: HIV/AIDS? * Yes No Date of Treatment * Heart Disease? * Yes No Date of Treatment * Alcoholism? * Yes No Date of Treatment * Drug Addiction? * Yes No Date of Treatment * Mental Disorder? * Yes No Date of Treatment * Cancer? * Yes No Date of Treatment * Do you have any mental health diagnoses? If yes, please list: * Alcohol Beverages Frequency * Never Occasionally Often Daily Quantity/Occasion * None 1/2 3/4 5/more Tobacco Tobacco Product Types * Frequency * Never Occasionally Often Daily Smoker quantity / daily # of packs * Chewing of dipping quantity / daily * Health Adoptive Father Health Status * Physical Limitations * Currently under a physicians care? * Yes No Please explain: * Any serious or prolonged illnesses or operations? * Yes No Please explain: * List all prescription medications and diagnosis: * Have you ever received treatment for or have any reason to suspect any of the following: HIV/AIDS? * Yes No Date of Treatment * Heart Disease? * Yes No Date of Treatment * Alcoholism? * Yes No Date of Treatment * Drug Addiction? * Yes No Date of Treatment * Mental Disorder? * Yes No Date of Treatment * Cancer? * Yes No Date of Treatment * Do you have any mental health diagnoses? If yes, please list: * Alcohol Beverages Frequency * Never Occasionally Often Daily Quantity/Occasion * None 1/2 3/4 5/more Tobacco Tobacco Product Types * Frequency * Never Occasionally Often Daily Smoker quantity / daily # of packs * Chewing of dipping quantity / daily * Christian Faith Denomination * Name of Church * Do you both attend church regularly? If no, please explain: * Views Regarding Adoption Why do you wish to adopt? * Do you have a preference as to sex, nationality, or physical characteristics? * Would you consider a child of another race or ethnic group? Please be specific. * Would you consider a physically or mentally challenged child? * Would you consider twins or a sibling group? Describe situations you are willing to consider. * Preferences regarding the age range of the child. Be specific: * Describe the degree of openness you are comfortable with in relation to meeting, talking with and possible long term face-to-face visits with the birthmother. * Family Photo * Drop a file here or click to upload Choose File Maximum file size: 367MB Adoptive Mother’s Signature * Clear Date * Adoptive Father’s Signature * Clear Date * Click here to read the New Beginnings Statement of Faith. Statement of Faith * I have read and agree with the agency’s statement of faith. If you are human, leave this field blank. Submit
