Please complete the following questionnaire thoroughly. All information given will be kept confidential. Please retain a completed copy for your records.
IDENTIFYING INFORMATION
(Must Be Completed AGAIN)
Prospective Adoptive Parent/Ap 1
Prospective Adoptive Parent/Ap 2
PHYSICAL DESCRIPTION
(Must Be Completed AGAIN)
Prospective Adoptive Parent/Ap 1
Prospective Adoptive Parent/Ap 2
EDUCATION*
*Complete if you have obtained any new degrees since last home study.
Prospective Adoptive Parent/Ap 1
Prospective Adoptive Parent/Ap 2
Hobbies, Interests, Community Activities
(Complete if anything is new or different)
Prospective Adoptive Parent/Ap 1
Prospective Adoptive Parent/Ap 2
Military
Prospective Adoptive Parent/Ap 1
WORK
(Complete only if changed since last home study)
Prospective Adoptive Parent/Ap 1
Prospective Adoptive Parent/Ap 2
HEALTH
(Must Be Completed AGAIN)
Prospective Adoptive Parent/Ap 1
Prospective Adoptive Parent/Ap 2
CLEARANCE QUESTIONS
(Must Be Completed AGAIN)
Prospective Adoptive Parent/Ap 1
Please answer these questions truthfully and explain any “yes” responses on separate sheet of paper. Yes questions will not necessarily preclude approval of a home study, if sufficient rehabilitation has been established. Failure to disclose will preclude an approval of a home study. You will also have a chance to discuss/explain any “yes” answers during the home visit.
Have you EVER:
** If yes, please get a certified final disposition from the court in the county where arrest occurred. The final disposition must include information from arrest to prove you served your sentence. If the court cannot provide any information, you must get a statement from the court saying no information is available. Then please provide a written statement in your own words giving details about the incident starting from what led up to the arrest to serving the sentence, and place the words “signed under penalty of perjury under U.S. law” and sign the letter (this is an additional task beyond the autobiography).
CLEARANCE QUESTIONS
(Must Be Completed AGAIN)
Prospective Adoptive Parent/Ap 2
Please answer these questions truthfully and explain any “yes” responses on separate sheet of paper. Yes questions will not necessarily preclude approval of a home study, if sufficient rehabilitation has been established. Failure to disclose will preclude an approval of a home study. You will also have a chance to discuss/explain any “yes” answers during the home visit.
Have you EVER:
** Please get a certified final disposition from the court in the county where arrest occurred. The final disposition must include information from arrest to prove you served your sentence. If the court cannot provide any information, you must get a statement from the court saying no information is available. Then please provide a written statement in your own words giving details about the incident starting from what led up to the arrest to serving the sentence, and place the words “signed under penalty of perjury under U.S. law” and sign the letter (this is an additional task beyond the autobiography).
HOUSEHOLD MEMBERS: Children/Others
(Must Be Completed AGAIN)
List ALL others living in your home including children, relatives, and/or boarders (if there has been a death of a child, please indicate the age of death and cause).
Household Member #1
Household Member #2
Household Member #3
Household Member #4
Household Member #5
Household Member #6
Household Member #7
List Other children not living in the home (if child is adopted and lives in another country, submit copy of adoption order) and for ADULT children living outside the home please provide their phone number so we may talk with them as part of the home study process.
Medical Doctor completing children(s) medical form(s):
GUARDIANSHIP INFORMATION*
*Complete if you have designated a new guardian since last home study.
It is a requirement to appoint a guardian for your adopted child in the event of your untimely death, debilitating accident or illness. Try to choose guardians under the age of 55 (if older than 55 choose a 2nd set of guardians also).
China guardians must be between 30-55 years of age.
Male
Female
PETS
(any domesticated pets new from last home study)
RESIDENCE*
* Complete if you live in a different home or have made improvements since last home study
HOME
BASEMENT
FINANCES
(Must Be Completed AGAIN with current financial information)
Prospective Adoptive Parent/Ap 1
Prospective Adoptive Parent/Ap 2
Assets:
Liabilities
NET WORTH: $
BUDGET
Insurances (Changes):
Health Insurance
Auto Insurance
Life Insurance
AUTHORIZATION AND ACKNOWLEDGEMENT
(Must Be Signed AGAIN)
I have read all instructional material in this form and have completed it to the best of my ability. I also state that I have read and understand the requirements and procedures defined by Adoption & Beyond. I hereby certify by my signature below that the foregoing application information and 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.
I understand this Application for Adoption is a vital tool in completing my home study assessment. Partial completion of this document or refusal to submit this or any other required or requested documentation may result in the termination of home study services or a non-approval of my home study.
I hereby authorize and consent to Adoption & Beyond, Inc., reviewing information regarding me and my background. These records will include, but not be limited to, health, social, educational, employment, marital information, references, etc. I understand that a photocopy of this authorization can be made as necessary.
I understand that approval of our home study assessment is the decision of Adoption & Beyond, Inc. I agree to inform Adoption & Beyond of any changes, which occur in my family or situation during the home study and/or adoption process.
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.
I have read and understand all of the above and the information I have provided is true and accurate: