|
Adoption Application
Form * Asterisk indicates required fields. |
|
|
*Last Name: |
|
|
*First Name: |
|
|
*Address: |
|
|
*City:
|
|
|
*State:
|
|
|
*Zip Code: |
|
|
*Phone: |
|
|
E-mail:
|
|
|
Web Site: |
|
|
|
Number of children at home: |
|
*Describe briefly your family including children or
anyone else living in the home.
|
|
*Please describe your faith in Christ.
|
|
*What are your reasons for wanting to adopt a special needs child?
|
|
1.What ages would you prefer?
0-2
2-4 4-8
8-12
12-16 Other
|
|
2.Are you interested in adopting a sibling group?
Yes
No Maybe
|
|
3.Are you open to adopting a child of color or mixed race?
Yes
No Maybe
|
4.If you are open to a child with a disability, what kind of
conditions do you feel you can handle? The world of disabilities is
often confusing because of the reality of the unknown. A doctor's
prognosis can be severe and yet a child could blossom under your love to be a
shadow of the problems foretold. On the other hand, a child may have no
indications of a particular medical need and end up having a prognosis you had
not planned on handling. |
|
Down syndrome
Respiratory
problems
Cerebral palsy
Mild
(limp, speech, learning delays)
Moderate
(speech, walks with walker, learning delays)
Severe
(no speech, wheelchair, etc..)
Blind
Visually Impaired
Deaf
Hearing
Impaired
Heart
defects
Mental retardation:
Mild
Moderate
Severe
Possible drug or alcohol effects such as.
-
Fetal Alcohol Syndrome
-
Fetal Alcohol Effect
Prematurely born
Cleft
Lip or Palate
Kidney problems
Bowel
incontinence
Family
back ground of mental illness
Multi-handicaps
Unknown
prognosis
|
Infectious
diseases:
HIV positive
Acquired
Immune Deficiency Syndrome (AIDS)
Hepatitis B:
carrier
Hepatitis
B: active
Dwarfism
Club
feet
Congenital
hip dislocation
Missing
appendages
Paralysis:
Partial
Full
Atresia (lack of opening such as
ear)
Spina Bifida
Seizures:
Controlled
Uncontrolled
Hydrocephaly
Microcephaly
Birthmarks
Nevus (large or unusual raised birthmark that may or may not be correctable.)
Diabetes
Terminal illness
Hemophilia
Failure to
thrive
|
Please Provide References |
|
*Name of Church: |
|
|
*Pastor or
Minister Name |
|
|
*Pastor Phone |
|
|
*Other Reference
Name |
|
|
*Other Reference
Phone |
|
|
*Letter To The Birth Mother
Please write a note to the birth mother:
|
