E-mail Address: * Date Name of Adopting Parent (Parent 1) Name of Other Adopting Parent (Parent 2) if applicable Street Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware 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 Washington, DC West Virginia Wisconsin Wyoming --Territories-- American Samoa Federated States of Micronesia Guam Midway Islands Puerto Rico U.S. Virgin Islands Zip Code Home Phone Parent 1 - Work Phone Parent 1 - Cell Phone Parent 1 - Email Address Parent 2 - Work Phone Parent 2 - Cell Phone Parent 2 - Email Address Parent 1 - Date of Birth Parent 1 - Race Parent 1 - Nationality Parent 1 - Any previous marriage(s)? yes no If yes: Please provide date(s) of marriage(s) and divorce(s) Parent 1 - Do you have any physical, mental health, or substance abuse issues that might affect your parenting? yes no If yes: Please describe. Parent 1 - Have you ever been convicted of any crime, other than minor traffic violations? yes no If yes: Please describe. Parent 1 - Please describe your hobbies and interests. Parent 1 - Religious or spiritual affiliation (if any). Parent 1 - If you are active with your religious or spiritual affiliation, please describe how. Parent 1 - Highest educational degree attained Parent 1 - Occupation Parent 1 - Briefly describe the work that you do. Parent 2 - Date of Birth Parent 2 - Race Parent 2 - Nationality Parent 2 - Any previous marriage(s)? yes no If yes: Please provide date(s) of previous marriage(s) and divorce(s). Parent 2 - Do you have any physical, mental health, or substance abuse issues that might affect your parenting? yes no If yes: Please describe. Parent 2 - Have you ever been convicted of any crime, other than minor traffic violations? yes no If yes: Please describe. Parent 2 - Please describe your hobbies and interests. Parent 2 - Religious or spiritual affiliation (if any). If you are active with any religious or spiritual affiliation, please describe how. Parent 2 - Highest educational degree attained Parent 2 - Occupation Parent 2 - Please describe briefly the work that you do. ALL PARENTS - Do you have any children? yes no If yes: Please provide the first name(s), gender(s), and race(s). Which (if any) of the children were adopted? From what country or countries were they adopted, and at what age(s)? Which (if any) of the children are from a previous marriage or relationship? Have you tried to adopt a child previously, without success? yes no If yes: Please explain. If you are married: How long have you been married? If you are in a committed relationship: How long have you been together? If you are single: How would you describe your support systems? What led you to the decision to adopt a child? If you are adopting with your partner or spouse - What differences are there between you about your priorities or preferences? Feel free to mention these differences as you answer the remaining questions. What are your biggest concerns about adopting a child? Are you currently working with an adoption agency and/or attorney? yes no If yes: Please provide name, city and state where they are located. Have you completed your home study? yes no If yes: Please provide the date the home study was completed. What is your budget range for your adoption process? Please describe any budget concerns or constraints. What are your plans for childcare after the adoption? (Examples: daycare, one parent staying at home, working part-time with childcare, etc.) How do you feel about contact with the birth parents before and after the birth of the baby? Please describe your perspective on open adoption. How long do you expect to wait before you adopt your baby? Please describe any concerns or requirements you have about the timeline. Do you have any preference for the gender of the child? girl boy no preference If you have a gender preference, please explain why. Please describe your preferences regarding the race or ethnicity of your child. If you indicated an interest in adopting a child of a race or ethnicity that is different from yours and that of your partner (if applicable), what do you see as the opportunities and challenges? If you prefer to adopt a child of a race or ethnicity that is the same as yours and that of your partner (if applicable), what are your reasons? Do you feel prepared to accommodate the needs of a child who has significant medical or physical challenges? yes no Please explain why or why not. Do you feel prepared to accommodate the needs of a child who was exposed to alcohol and/or drugs prenatally? yes no Please explain why or why not. Please describe any other priorities or concerns you have about your future child and his or her birth parents. Is there anything else you would like us to know? * Required