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?
 Yes No
Are there pets in the home?
 Yes No
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 American Asian Biracial Caucasian Hispanic Native American
Other:

Preferred sex
 Female Male Either
Preferred age
 0 - 6 yrs. 7 - 10 yrs. 11 - 14 yrs. 15 & over
How many at this time?
 One Two Three Four Any 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:
 ADD ADHD Adjustment Disorder AIDS/HIV Animal Abuse Anxiety Disorder Asthma Attachment Disorder Autism Bipolar Blind Cerebral Palsy/Mild Cerebral Palsy/Moderate Cerebral Palsy/Severe Conduct Disorder Deaf Depression Developmental Delays Diabetes Down Syndrome Drug Exposed Eating Disorders Emotional/Mild Emotional/Moderate Emotional/Severe Encopresis Enuresis Epilepsy Failure to Thrive Fetal Alcohol Syndrome Fire Starter Heart Murmur Hydrocephalic Hyperactivity Learning Disability Legal Risk Macrocephalic Mental Retardation/Mild Mental Retardation/Moderate Mental Retardation/Severe Microcephalic Missing Limbs Mood Disorder Muscular Dystrophy Non-Ambulatory Non-Verbal Obsessive-Compulsive Disorder Oppositional Defiant Disorder (ODD) Paralysis Physically Abused Physically Aggressive Post-Traumatic Stress Disorder (PTSD) Quadriplegia Reactive Attachment Disorder (RAD) Runaway Schizophrenia Scoliosis Seizures Self-Abusive Sexually Abused Sexually Acting Out Shaken Baby Syndrome Sickle Cell Spina Bifida Terminal Illness Total Care Tourette Syndrome Trach Tube 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/flier Radio TV Newspaper Internet web page Magazine Recruitment events Business cards
Has Adopt America Network (AAN) assisted to you in any way for any of your adopted children?
 Yes No
If yes, which child(ren)?
Have you completed an adoption (not foster) home study and been approved for adoption?
 Yes No
Date
Are you licensed for foster care?
 Yes No
If no, are you in a home study now?
 Yes No
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.