Online Pre-Application
FAMILY INFORMATION
First Name *
Last Name *
Spouse First Name
Spouse Last Name
Address *
City *
State *
Zip
Home Phone
Email *
Are you currently adopting through ADOPT ABROAD?
Yes
No
Where are you in the adoption process?
Application
Dossier
Referral
Citizenship (Mom)
Citizenship (Dad)
Race (Mom)
Race (Dad)
Religion (Mom)
Religion (Dad)
Educational Background (Mom)
Educational Background (Dad)
Annual Household Income
Household Net Worth
Number of Previous Marriages (Mom)
Number of Previous Marriages (Dad)
Marriage Date
Number and Ages of Children in the Home
List all current and past diagnosed health conditions
List all medications you are currently taking
List all past surgeries with dates and recovery status
Do you have any arrests, regardless of outcome?
Yes
No
Please provide additional information including dates, type of charge, description of events leading to the arrest and outcome of the arrest
Have you ever terminated your parental rights or had your parental rights terminated?
Yes
No
Have you ever placed a child for adoption?
Yes
No
Home study?
Yes
No
Home study Agency
Home study Date
CHILD INFORMATION
Gender
Male
Female
Either
Age Range (check all that apply)/ MONTHS
12 Months or Younger
12-24 months
24-36 months
36-48 months
48-60 months
YEARS
5-6 Years
6-7 Years
7-8 Years
8-9 Years
10-11 Years
11-12 Years
13-14 Years
We will consider parenting a child diagnosed with only minor/correctable medical needs
We will consider a child that may require long term treatment and/or care
We will consider a child who has more than one special need
We would accept a healthy child over the age of 8 years old
In the following section, please review each medical need and only check the medical needs that you would
seriously consider
.
I
would consider
a child with the following medical conditions (check all that apply):
In the following section, please review each medical need and only check the medical needs that you would seriously consider. A description of each need and explanation of each item listed can be found in our Waiting Child Medical Glossary. Please use this glossary for reference as you complete your checklist.
Blood Conditions
Cancer
Hemophilia
Phenylketonuria
Thalassemia A
Thalassemia B intermedia
Thalassemia B major
Developmental
Autism
Developmental Delay (Gross motors skills)
Developmental Delay (Global)
Developmental Delay (Language)
Developmental Delay (Sozial Skills)
Central Nervous System
Arachnoid Cyst
Cerebral Palsy (mild)
Cerebral Palsy (moderate)
Cerebral Palsy (severe)
Epilepsy
Hydrocephalus
Microcephaly
Neurofibromatosis
Spina Bifida (post-operative)
Spina Bifida (pre-operative)
Heart
Mild
Moderate
Severe
Infectious Diseases
Encephalitis
Hepatitis B
Syphilis
Tuberculosis
Craniofacial
Cleft lip and palate, unilateral (pre-operative)
Cleft lip and palate, unilateral (post-operative)
Cleft lip and palate, bilateral (post-operative)
Cleft lip and palate, bilateral (pre-operative)
Cleft lip and palate, Cleft lip (II-III degree)
Cleft palate (III degree)
Eye/Orbital deformity
Facial deformity
Microtia (Unilateral)
Microtia (Bilateral)
Orthopedic
Hip Dysplasia
Dwarfism
Deformity of fingers and/or toes
Complete absence (More than 1 limb)
Complete absence (1 limb)
Clubbed hands (Bilateral)
Clubbed hands (Unilateral)
Clubbed feet (Bilateral)
Clubbed feet (Unilateral)
Brachial Plexus Injury
Arthrogryposis
Paraplegia
Requires assistance to walk (not wheelchair bound)
Rheumatoid Arthritis
Rickets
Scoliosis (slight curvature)
Scoliosis (significant curvature)
Short/webbed neck
Underdevelopment/maldevelopment (1 limb)
Underdevelopment/maldevelopment (More than 1 limb)
Sensory
Hearing loss (Partial)
Hearing loss (Complete)
Vision impairment
Vision loss (Partial)
Vision loss (Complete)
Skin Conditions
Albinism (also involves vision)
Burns (involves significant scarring)
Ichthyosis
Nevus/hairy nevus (Small)
NeNevus/hairy nevus (Large)
Nevus/hairy nevus (Multiple)
Vascular
Capillary malformation (Port wine stain)
Hemangioma
Lymphangioma
Urogenital
Anorchism
Cryptorchidism
Funicular Hydrocele
Hermaphroditism
Hypospadias (Mild)
Hypospadias (Severe)
Imperforate anus
Incontinence
Rectal/vaginal fistula
Underdeveloped/ambiguous genitalia
Nephrological
Hydronephrosis
Polycystic Kidneys
Please be as detailed as possible in answering the questions below, as this information will be reviewed to determine the best match for your family and the child.
Why does your family wish to pursue a Waiting Child adoption?
Describe any experience your family has with individuals with special needs (personal and professional)
What types of resources are available to your family that will help you meet the needs of a special needs and/or older child? Please include medical resources as well as family and community support.
How will you handle any future conditions that may arise as a result of the special medical need? Does your health insurance cover pre-existing condition? If not, how do you plan to finance medical treatment for the child?
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