I am interested in:
____ International___Waiting Child___US Infant___Designated Infant Adoption
___LaFamilia Infant Adoption___Adoption for Black Children (ABC) ___Kinship
Name: __________________________________________________________
Date of Birth: __________________________________
Complete Address: ________________________________________________
______________________________________________________
Home Phone: ______________________ Cell: _________________________
Work Phone: _______________________ Fax: _________________________
E-mail: ____________________________
Spouse/Partner: _______________________________
Date of Birth: __________________________________
Home Phone: ______________________ Cell: _________________________
Work Phone: _______________________ Fax: _________________________
Are there children in the home? ___Yes ___No
If yes, what are their names and ages? ________________________________
Others living in the home: ___________________________________________
I am interesting in adopting the following type of child: (*Optional for Waiting Child and International ONLY)
*Male___ *Female___ Either___ Country______________________________
Age Range: __________ Siblings_____ Number_____
Racial/Ethnic Background____________________________________________
Date of Marriage____________________________
Dates of any previous marriages or divorces_____________________________
Employment (Applicant):
Employer_________________________________________________________
Job Title:________________________________ Salary___________________
Employment (Spouse/Partner):
Employer_________________________________________________________
Job Title:________________________________ Salary___________________
Will one parent be able to take a leave when the child arrives? Yes___ No____
Do you have health insurance that will cover a child upon placement? Yes__No__
Has a child ever been removed from your home? Yes____ No____
Have you or anyone living in your home ever been arrested, charged, or convicted of a criminal offence? Yes____ No____
If “yes” to either of these last two questions, please attach a letter of
explanation.
Do you feel particularly able to parent a child with emotional problems, developmental delays, or a physical disability? If so, what type of problems do you not feel you can handle and why.
Briefly, why do you wish to adopt?
FAMILY ASSESSMENT (HOME STUDY) STATUS:
We are required to contact previous agencies with whom you have worked. Have you ever applied to another agency for adoption or foster care?
Yes___ No___ If so, was a previous family assessment completed?
Yes___ No___ Date Completed____________
Previous agency:
Name___________________________________________________________
Address__________________________________________________________
Phone___________________ Caseworker______________________________
OUT-OF-STATE FAMILIES:
Do you have a state-approved agency or caseworker available to do your family assessment? Yes____ No____
If “Yes”, please provide Name________________________________________
Address__________________________________________________________
Phone________________________
Caseworker_______________________________________________________
I/We understand that the Preliminary Application fee of $150 for all Traditional Infant and Designated adoptions, or $100 for all other programs (Waiting Child, International adoptions) is non-refundable, and does not guarantee receipt of a Formal Application or placement of a child.
Applicant Agrees: Yes____ No____ Date:______________________
Spouse/Partner Agrees: Yes____ No____ Date:______________________
Please submit application and application fees by mail to:
Adoption Alliance, 2121 S Oneida St, Ste 420, Denver, CO 80224-2575.
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