REFERRED BY___________________________________________

 

PRELIMINARY INFORMATION (Please print this adoption application, fill it out and mail to our address)
	ADOPTIVE MOTHER	ADOPTIVE FATHER
Name	______________________________	______________________________
Address	______________________________	______________________________
	______________________________	______________________________
How Long	______ Own ___ Rent _____	______ Own ___ Rent _____
Birthplace	______________________________	______________________________
Date of Birth	______________________________	______________________________
Age	___ Social Security # ____________	___ Social Security # ____________
Physical Description	Ht. _______ Wt. ________	Ht. _______ Wt. ________
Eyes	______ Hair ____________	______ Hair ____________
Race	______________________________	______________________________
Marriage Date ___________________________
Home Phone Number	______________________________	E-Mail Address __________________
Cell Phone Numbers	______________________________	_______________________________
Work Phone Numbers	______________________________	_______________________________
Children / Ages / Natural or Adopted
	______________________________	_______________________________
Religion	______________________________	______________________________
Nationality	______________________________	______________________________
Highest Grade Completed	______________________________	______________________________
Special Interests or Talents	______________________________	______________________________
	______________________________	______________________________
Military Service	______________________________	______________________________
Occupation	______________________________	______________________________
Employer / Address / Phone Number
	______________________________	______________________________
Address	______________________________	______________________________
Approx. Annual Income	$_____________________________	$_____________________________
Have you ever been arrested or convicted of a Crime other than Minor Traffic Violations? (If the answer to this question is "yes", please explain on an attached sheet of paper.)
	Yes ______ No ______	Yes ______ No ______
Do you drink Alcohol?	Yes ______ No ______	Yes ______ No ______
Do you smoke?	Yes ______ No ______	Yes ______ No ______
Family Medical History Any serious or chronic illness including mental or psychiatric treatment?
	______________________________	______________________________
	______________________________	______________________________
	______________________________	______________________________
Has your infertility been diagnosed?		______________________________
Reason?	___________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

ADOPTIVE MOTHER

How long have you been interested in adoption and why do you want to adopt?

___________________________________________________________________________________

___________________________________________________________________________________

How do you feel about your spouse as a parent?

___________________________________________________________________________________

___________________________________________________________________________________

ADOPTIVE FATHER

How long have you been interested in adoption and why do you want to adopt?

___________________________________________________________________________________

___________________________________________________________________________________

How do you feel about your spouse as a parent?

___________________________________________________________________________________

___________________________________________________________________________________

Have you applied to other adoption agencies / attorney's, and where?

___________________________________________________________________________________

Would you accept a "Special Needs" Child?	Yes ______	No ______
Mild Physical Handicap?	Yes ______	No ______
Moderate Physical Handicap?	Yes ______	No ______
Severe Physical Handicap?	Yes ______	No ______
Mild Mental Handicap?	Yes ______	No ______
Moderate Mental Handicap?	Yes ______	No ______
Severe Mental Handicap?	Yes ______	No ______
Would you accept a Racially-Mixed Child?	Yes ______	No ______
Black/ White	Yes ______	No ______
Hispanic/White	Yes ______	No ______
Asian / White	Yes ______	No ______
Would you accept an Black, Hispanic or Asian Child?	Yes ______	No ______
Asian	Yes ______	No ______
Hispanic	Yes ______	No ______
Black	Yes ______	No ______
Would you accept an older child?	Yes ______	No ______
Up to what age?	________
Would you accept a sibling group?	Yes ______	No ______
What ages?	________

Other Comments
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Please include these documents when submitting your application:
1. Completed Application - Please make sure the application is fully completed and signed by both adoptive parents.
2. Local Law Enforcement Clearance - This is to be completed by your local police station.
3. Florida Department of Law Enforcement Clearance - A check or money order must be submitted along with this request made payable to "FDLE." The fee is $23.00 per person. Each adoptive parent must sign this clearance.
4. Abuse Registry Clearance - No fee required.
5. Financial Statement - Statement of assets and liabilities in a balance sheet type format or your most recent Federal Income Tax statement.
6. Please include some recent family photographs.
Please supply 6 references, one of which may be from a relative. Additionally, please supply a letter from your employer or a colleague at work. The letters should indicate how long the reference has known you and why they feel you'll make a great parent. Your application will not be complete until we receive all your reference letters, so please choose references who will respond quickly.
Name:   ________________________   Name:   ________________________ Address: ________________________ Address: ________________________ ________________________ ________________________ Phone: ________________________ Phone: ________________________ *** *** *** *** Name: ________________________ Name: ________________________ Address: ________________________ Address: ________________________ ________________________ ________________________ ________________________ Phone: ________________________ *** *** *** *** Name: ________________________ Name: ________________________ Address: ________________________ Address: ________________________ ________________________ ________________________ Phone: ________________________ Phone: ________________________ *** *** *** ***   * Please note this application to adopt and your consultation with one of our attorneys is for your opportunity to be considered as a future client of our office. After your consultation and submission of your application and reference letters, you will be entitled to have your profile presented to individual birth mothers as we meet them. You will become a client of our office when you retain us and accept a specific birth mother for adoption of her child.   Signed this _____ day of _______________, 20___.   ______________________________________ ADOPTIVE MOTHER   ______________________________________ ADOPTIVE FATHER