Information for Home Study Addendum

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Name(Required)

First Last

Phone(Required)

Email(Required)

NOTE: Completing an addendum to your home study does not extend the approval date of the home study being amended; it simply reflects updated information within the current home study report.

GENERAL INFORMATION:

Name of Prospective Adoptive Parent(s):

REASON ADDENDUM IS NEEDED:

CHANGE OF RESIDENCE/ADDRESS

CHANGE IN EMPLOYMENT

CHANGE IN AGE, GENDER, RACE OR NEEDS OF CHILD REQUESTED

ADDITIONAL HOUSEHOLD MEMBER

CHANGE IN COUNTRY REQUESTED

(Please check ALL that apply)

CHANGE OF RESIDENCE/ADDRESS:

Original Address

New Address

CHANGE IN EMPLOYMENT:

List Original Employers

Original Employer(s)

Previous Annual Salary

New Employer

New Annual Salary

Why the change in employment?

CHANGE IN AGE, GENDER, RACE OR NEEDS OF CHILD REQUESTED:

Original Age/Gender/Race Requested:

Current Age/Gender/Race Requested:

Special Needs, if any that you are now willing to accept. (Leave blank if none.)

Why the change in child requested?

ADDITIONAL HOUSEHOLD MEMBER:

Name of Household Member:

Date of Birth:

Relationship to family:

Grade/Occupations:

Had a Criminal History?

Please provide all states/countries they have lived in since turning 18 years of age and the years of residency in those states/countries.

State/ Country

Residence Start Year

Residence End Year

CHANGE IN COUNTRY REQUESTED:

Original country requested:

Country

New country requested:

Country

ADDITIONAL DETAILS:

ANY ADDITIONAL DETAILS OF CHANGE(S) NEEDED:

ACKNOWLEDGMENT:

We (I) have read all instructional material in this form and have completed it to the best of our (my) ability. We (I) also state that we (I) have read and understand the requirements and procedures defined by Adoption & Beyond. We (I) hereby certify by our (my) signature(s) below that the foregoing application information and our (my) statements therein are correct and true and understand that falsified statements on this or subsequent paperwork or contact, both written and/or verbal shall be grounds for termination of services. In addition, withholding and/or providing misleading information shall also be grounds for termination of services.

We understand this Application for Adoption is a vital tool in completing our (my) home study assessment. Partial completion of this document or refusal to submit this or any other required or requested documentation may result in a non-approval of our (my) home study.

We (I) hereby authorize and consent to Adoption & Beyond, Inc., reviewing information regarding us (me) and our (my) background. These records will include, but not be limited to, health, social, educational, employment, marital information, references, etc. We understand that a photocopy of this authorization can be made as necessary.

We (I) understand that approval of our home study assessment is the decision of Adoption & Beyond, Inc. We (I) agree to inform Adoption & Beyond of any changes, which occur in our (my) family or situation during the home study and/or adoption process. I understand that by completing an addendum to my current home study, this addendum does not extend the approval date of the current home study; it simply reflects updated information within the home study report.

Adoption & Beyond and its representatives assume no responsibilities and will not be held liable for the statements, acts or failure to act by any other entity including but not limited to birth parents, attorneys, doctors, government agencies, orphanages, public officials and/or other child placing entities.

We (I) have read and understand all of the above and the information we have provided is true and accurate:

Signature of Prospective Adoptive Parent

Date

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