Adoptive Families Request for Information Home Looking to Adopt? Adoptive Families Request for Information Adoptive Families Request for Information Completing this form should take less than 2 minutes. Please make sure to answer all the questions to give us an overview of you and your adoption goals. Make sure to hit the “Submit Request Now” button at the end. Thank you! [group step-one] How did you hear about our agency? —Please choose an option——Please choose an option——Please choose an option—Internet SearchFacebookInstagramYouTubeMobile AppInternet AdNewspaperYellow PagesReferred by friendOther Adoptive Parent 1 First Name * Last Name * Cell Phone Number * Area code cannot start with 0 or 1. Email Address * What is your Birthday? Month Day Year Gender —Please choose an option——Please choose an option——Please choose an option—MaleFemale What Race are you? —Please choose an option——Please choose an option——Please choose an option—African AmericanAfrican American / AsianAfrican American / HispanicAsianCaucasianCaucasian / African AmericanCaucasian / AsianCaucasian / HispanicHispanicHispanic / Asian Next [/group] [group step-two] Adoptive Parent 2 First Name Last Name Cell Phone Number Area code cannot start with 0 or 1. Email Address What is your Birthday? Month Day Year Gender —Please choose an option——Please choose an option——Please choose an option—MaleFemale What Race are you? —Please choose an option——Please choose an option——Please choose an option—African AmericanAfrican American / AsianAfrican American / HispanicAsianCaucasianCaucasian / African AmericanCaucasian / AsianCaucasian / HispanicHispanicHispanic / Asian Back Next [/group] [group step-three] Address Address City Address State —Please choose an option——Please choose an option——Please choose an option—AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNYNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Back Next [/group] [group step-four] Adoption Preference Personal Visits (Open) —Please choose an option——Please choose an option——Please choose an option—YesNoby Case Send Pictures and Letters (Semi-Open) —Please choose an option——Please choose an option——Please choose an option—YesNoby Case No Contact (Closed) —Please choose an option——Please choose an option——Please choose an option—YesNoby Case Are you open to a Birthmother that uses Nicotine? —Please choose an option——Please choose an option——Please choose an option—YesNoby Case Are you open to a Birthmother that consumes Alcohol? —Please choose an option——Please choose an option——Please choose an option—YesNoby Case Are you open to a Birthmother that uses Marijuana? —Please choose an option——Please choose an option——Please choose an option—YesNoby Case Are you open to a Birthmother that uses Illicit Drugs? —Please choose an option——Please choose an option——Please choose an option—YesNoby Case Are you open to a Birthmother that has been treated for Mental Disorders? —Please choose an option——Please choose an option——Please choose an option—YesNoby Case What Gender are you seeking? —Please choose an option——Please choose an option——Please choose an option—BoyGirlNo Preference What is the highest percentage of any given race would you consider adopting? Caucasian —Please choose an option——Please choose an option——Please choose an option—100%50%0% African American —Please choose an option——Please choose an option——Please choose an option—100%50%0% Hispanic —Please choose an option——Please choose an option——Please choose an option—100%50%0% Asian —Please choose an option——Please choose an option——Please choose an option—100%50%0% What is your adoption budget for Legal Expenses? (FORMAT numeric only) What is your adoption budget for Birthmother Living Expenses? (FORMAT numeric only) Do you have a completed Home Study? —Please choose an option——Please choose an option——Please choose an option—YesNo Date Home Study completed (FORMAT mm/dd/yyyy) Month Day Year Back [/group]
