Preliminary ApplicationPreliminary Application Preliminary Application Please confirm you have read and understand the New Beginnings Statement of Faith * 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 Alabama Alaska Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State/Province Zip/Postal Zip/PostalDo you have an approved home study completed? * Yes No When does it expire? * What agency completed it? * Highest Level of EducationAdoptive Mother Name of School * Location of School * Year Graduated * Degree Earned * Adoptive Father Name of School * Location of School * Year Graduated * Degree Earned * EmploymentAdoptive 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 MotherFirst Marriage? * Yes NoHave you ever been divorced? * Yes NoAdoptive FatherFirst Marriage? * Yes NoHave you ever been divorced? * Yes NoFinancesAdoptive Mother Yearly Gross Salary * Other Sources of Income/Amount * Adoptive Father Yearly Gross Salary * Other Sources of Income/Amount * Criminal HistoryAdoptive MotherHave 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 FatherHave 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: * HealthAdoptive 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: * AlcoholBeverages Frequency * Never Occasionally Often DailyQuantity/Occasion * None 1/2 3/4 5/moreTobacco Tobacco Product Types * Frequency * Never Occasionally Often Daily Smoker quantity / daily # of packs * Chewing of dipping quantity / daily * HealthAdoptive 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: * AlcoholBeverages Frequency * Never Occasionally Often DailyQuantity/Occasion * None 1/2 3/4 5/moreTobacco 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 upload size: 104.86MB Adoptive Mother's Signature * Clear Date * Adoptive Father's Signature * Clear Date * Click here to read the 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 GIVE TO SUPPORT EVENTS RESOURCESHEAD OFFICE2164 Southridge Drive Tupelo, MS 38801Call Us(T): 1.662.842.6752(F): 1.662.840.7176EMAIL USadopt@newbeginningsadoptions.org © All rights reserved. Site by imavex.
