The Adoption Exchange: Inquiry on a child

Child Desired

Important Note: Since this form is forwarded to each child's caseworker, you must submit a separate form for each child or sibling group you are interested in. Simply click your browser's "back" button after each form submission and change the child's name below. Your browser should remember your information so you do not need to complete the entire form over again... just the child's name. After you change the child's name, you must resubmit the form again (click on "Submit Form" at the bottom).

Is there a specific child you are interested in?
Name:
State:
Child ID #:

Applicant Information

Name:

Name Title	Name First Required	Name Last Required	Name Suffix

Email:

Street 1:

Street 2:

City/State/ZIP:

City	State	ZIP

County:

Country:

Phone Number:

Occupation:

Gender:

Ethnicity:

Religion:

Date of Birth:

Month

Day

Year

Remember me.

What's this?

Marriage Information

Marital Status:
Date Married (mm/dd/yyyy):

Spouse/Partner Information

Spouse/Partner First Name:
Spouse/Partner Last Name:
Spouse/Partner Gender:	Male Female
Spouse/Partner Ethnicity:
Spouse/Partner Religion:
Spouse/Partner Email:

Family Information

The information requested below is very important to each caseworker.
Please be sure to select or provide answers and information thoroughly
in each drop-down box and text field below on each inquiry you submit.

How many children have you parented?

Do any of them have disabilities?

If yes, please indicate which type(s):

Cognitive Impairment
Physical Disability
Medically Fragile
Mental/Behavioral Challenges

Please list diagnoses:

Have you adopted any of your children?

*	Please list the following information for each child living in your home OR indicate "No children in the home": This information is mandatory. Gender; date of birth; adopted, foster or birth child. For example: Boy; 3/3/96; adopted.

Home Study Information

Have you a completed homestudy?
This information is critical to your inquiry process.

Date most recent homestudy completed or updated: (mm-yyyy) Date is required to be considered as a Homestudied family *Correct information is critical to your inquiry process
Caseworker:
Agency:
Caseworker Phone:
Caseworker Email:
Caseworker Address:
Has your adoptive homestudy or foster care license ever been denied or revoked?

Adoptive Child Information

Youngest age you will consider:
Oldest age you will consider:
Would you consider siblings?
If yes, what is the largest # of siblings you could consider?
Preferred Gender:

Preferred Ethnicity (choose "yes" for all that apply):

Anglo/Caucasian
Asian
Black/African American
Hispanic
Native American
Multiracial
No Preference

Please check the most severe degree of special need a child has that you would consider:

Emotional:	None Mild Moderate Severe
Physical:	None Mild Moderate Severe
Mental Retardation (cognitive disabilities):	None Mild Moderate Severe
Learning Disability:	None Mild Moderate Severe

Sexually Abused:

Choose "yes" for all that you would consider:

Legal Risk
Down Syndrome
Fetal Alcohol Effects/Fetal Alcohol Syndrome
Hearing Impairment
Visual Impairment
Cerebral Palsy
Medically Fragile
ADD/ADHD

How did you first learn about The Adoption Exchange?

List any additional information from the previous question here:

Comments:

Comments may include your parenting experience, experience with children like this child,
family strengths, interests, and any adoption training. Also include anything you would like this
child's caseworker to know about you.

Each of these inquiries is forwarded to the child's caseworker. You may have made a number
of inquiries; please be aware that each inquiry may be going to a different caseworker, so you
need to fill out this box each time. (Helpful hint: store your comments for caseworkers in a
word document, then cut and paste into this box.)

Please limit your comments to 300 words or less
(the size of the comments window).

Information provided in this form will be entered into our database and may be forwarded to caseworkers and/or agencies as a potential match for other children.