Is there room in your heart and in your home?

For those families with a current home study, or if you have completed the home study process, please fill out the Family Registration Form below and submit  it to us.  Please email us and attach your home study and digital photographs.  If you prefer, you may print the Family Registration Form and send it  via U.S. mail along with the completed home study to the address above. Once we receive it, you will be registered as a prospective adoptive family. If you are currently registered or have previously completed this form, please contact the Registration Department at 1-800-246-1731 or send an email.

Family Registration Form

Applicant #1
DOB
M/F
Occupation
Business phone
Applicant #2
DOB
M/F
Occupation
Business phone
Home Phone
E-mail
Address
City
State
ZIP
County
Marital status
Religion
Sign language
Languages spoken
How many children
have you raised?
Are there smokers in the home?
YesNo
Are there pets in the home?
YesNo
Children living at home:

First names
M/F
DOB
Biologic
True
Adopted
True
Foster
True
Challenges

True
True
True

True
True
True

True
True
True

True
True
True

True
True
True

True
True
True

True
True
True

True
True
True

Please check all types of child(ren) you would consider adopting.
Preferred race
African AmericanAsianBiracialCaucasianHispanicNative American
Other:

Preferred sex
FemaleMaleEither
Preferred age
0 - 6 yrs.7 - 10 yrs.11 - 14 yrs.15 & over
How many at this time?
OneTwoThreeFourAny number
The youngest age child I will consider is:
The oldest age child I will consider is:
Please check the following challenges that you will consider in a child:
ADDADHDAdjustment DisorderAIDS/HIVAnimal AbuseAnxiety DisorderAsthmaAttachment DisorderAutismBipolarBlindCerebral Palsy/MildCerebral Palsy/ModerateCerebral Palsy/SevereConduct DisorderDeafDepressionDevelopmental DelaysDiabetesDown SyndromeDrug ExposedEating DisordersEmotional/MildEmotional/ModerateEmotional/SevereEncopresisEnuresisEpilepsyFailure to ThriveFetal Alcohol SyndromeFire StarterHeart MurmurHydrocephalicHyperactivityLearning DisabilityLegal RiskMacrocephalicMental Retardation/MildMental Retardation/ModerateMental Retardation/SevereMicrocephalicMissing LimbsMood DisorderMuscular DystrophyNon-AmbulatoryNon-VerbalObsessive-Compulsive DisorderOppositional Defiant Disorder (ODD)ParalysisPhysically AbusedPhysically AggressivePost-Traumatic Stress Disorder (PTSD)QuadriplegiaReactive Attachment Disorder (RAD)RunawaySchizophreniaScoliosisSeizuresSelf-AbusiveSexually AbusedSexually Acting OutShaken Baby SyndromeSickle CellSpina BifidaTerminal IllnessTotal CareTourette SyndromeTrachTube Fed

Other conditions, syndromes, problems
Describe any skills, knowledge, or experience with special needs children you may have.
Describe any conditions or behaviors you cannot accept.
Please give us a brief description of your family, your lifestyles, your interests, etc.
Please attach a photo of your family.
Please check and sign for permission to feature your family in any or all recruitment events available.
Adopt America newsletter/flierRadioTVNewspaperInternet web pageMagazineRecruitment eventsBusiness cards
Has Adopt America Network (AAN) assisted to you in any way for any of your adopted children?
YesNo
If yes, which child(ren)?
Have you completed an adoption (not foster) home study and been approved for adoption?
YesNo
Date
Are you licensed for foster care?
YesNo
If no, are you in a home study now?
YesNo
Expected date of completion
SOCIAL WORKER AND AGENCY INFORMATION MUST BE COMPLETE IF APPLICABLE
Social worker
Phone
E-mail
Fax
Name of agency
Address
City
State
ZIP

By checking this box, I (we) hereby authorize the above agency to release my adoption home study to Adopt America Network. This also authorizes Adopt America Network to send our (my) Home Study out to child agencies on our (my) behalf.

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