Gladney Center for Adoption Placement Application*

Dear Prospective Adoptive Parents,

Should you have questions regarding your eligibility for a specific program, please first speak to a member of our staff before completing the application. Here you will find information about our adoption service policies and practices, including general eligibility criteria and fees under each of our adoption programs. You can find more information about our number of placements, applications and number of waiting children here. Should you proceed, you will be asked to sign a contract like the sample found here. If you are in a state outside of Arkansas, Delaware, Florida, Illinois, Missouri, New Jersey, New York, North Carolina, Oklahoma, Pennsylvania, or Texas, you will need a home study provider in your state. A list of already approved supervised provider partners can be found here. Should you wish to work with an alternative provider, we will need to approve them in advance.

We appreciate your time in telling us about your family and completing the application below. We realize there are a lot of preliminary questions, but all of this is designed to help match each child with the most appropriate family and to understand the unique circumstances of your adoption journey. Please make sure you click on the SUBMIT button to electronically submit the application. Your application will not be received or processed if you do not submit this online.

The application fee is $600 for new clients, or $350 for returning placement clients, and is non-refundable.

The following payment options will be available:

Pay online via PayPal (a link will be provided after submission of the application)
Mail a check made payable to: Gladney Center for Adoption. Please indicate “Application Fee” in the Memo section of your check. Mail to: 1102 Society Drive, Claymont, DE 19703.

PLEASE NOTE: Your application cannot be processed until BOTH the online application AND fee are received by Gladney Center for Adoption.

*FOR NEW YORK FAMILIES ONLY, this form is a PRE-application. Once this initial form is reviewed, approved and accepted, each prospective adoptive applicant will need to fill out our New York specific application which will be forwarded to your designated email address.

Fields with "*" are required. If the field does not apply, please enter "NA." With the exception being: if you are applying as a single parent, please leave ALL 'Ap 2' fields blank.

We may be able to save you time by pre-filling the form with the information that you have previously entered.

Have you previously submitted your information to us?

Yes, Login

No, Begin Form

Marital Information
Marital Status*

If married, Date of Marriage

Location of Marriage

Ap 1: Number of Prior Divorces*

Ap 1: Date of Most Recent Divorce*
*
Ap 2: Number of Prior Divorces*
*
Ap 2: Date of Most Recent Divorce

Religion
Madison Adoption Associates is committed to providing an environment that is free from discrimination. Madison Adoption Associates will ensure equal opportunity for all people without regard to race, color, religion, creed, national origin, gender, sexual orientation, age, ancestry, marital status, disability, veteran or draft status. The questions below are intended for the Country in which you are applying to adopt.
Ap 1 Religion (required for Philippines Program)*

Ap 1's Active Church Member*
YesNo
Ap 1's Amount of Religious Involvement*

Ap 2 Religion (required for Philippines Program)*
*
Ap 2 Active Church Member (required for Philippines Program)*
YesNo*
Ap 2's Amount of Religious Involvement*
*
If Applicants have different religions, what religion would child be reared?

Previous Home Study
Have you ever had a previous home study process started?*
YesNo
What agency completed your previous home study (if applicable)?*
*
Estimated Date home study process began*
*
Date home study process was completed or terminated*
*
Have you ever been the subjects of an unfavorable home study or been rejected as prospective adoptive parents?*
YesNo
If Yes, please explain*
*

Family Contact Information

Street Address*

Street Address Line 2

City*

State/Region*

Enter Region

Zip Code*

Country*

Show All Countries

Home Email*

Home Phone Number*

()-ext

Enter Int'l Number

Fax Number

()-ext

Enter Int'l Number

Family Shipping Address

Only enter Shipping Address if it is different from the Residence Address.

Shipping Street Address

Shipping Street Address Line 2

Shipping City

Shipping State/Region

Enter Region

Shipping Zip Code

Shipping Country

Show All Countries

Family Photo
If you do not have an electronic photo available, please mail a photo to our office (labeled with your name and contact information). Once uploaded, your photos will not be viewable except by agency staff for security purposes.
Photo Upload #1*

Please upload a Family Picture
Photo Upload #2

Please upload a Passport Style photo for Applicant 1
Photo Upload #3

Please upload a Passport Style photo for Applicant 2
Photo Upload #4

Please Upload a picture of your home
Photo Upload #5

Please upload an additional Family Picture

Password
Please enter a password to use at a later time to access other forms on our website. Please write down and keep this password in a safe place.
Family Login Password*
Password Already Set Change Password
Confirm Password	*
Password must be at least 8 characters with at least one uppercase letter, one lowercase letter, one number, and one special character.

Education

	Ap 1 Education Level*	Ap 2 Education Level

Academic History

Family Details - Academic History

Prospective Adoptive Parent*	Academic Institution*	Location*	Type of Degree*	Year of Completion*

PAP 1 Military Service/First Responder
Ap 1 Military Service
Ap 1 DD Form 214 Received
Ap 1 First Responder Job
Ap 1 Verified by Employment Letter

PAP 2 Military Service/First Responder
Ap 2 Military Service
Ap 2 DD Form 214 Received
Ap 2 First Responder Job
Ap 2 Verified by Employment Letter

Prospective Adoptive Parent 1 Work

Ap 1 Employer*

If you are employed outside of the home, when did you become employed at your current job?*

Ap 1 Occupation/Title*

Ap 1 Work Street Address*

Ap 1 Work City*

Ap 1 Work State/Region*

Enter Region

Ap 1 Work Zip Code*

Ap 1 Work Phone*

()-ext

Enter Int'l Number

Prospective Adoptive Parent 1 Finances
Ap 1 Annual Income*	$
Ap 1 Other Annual Income
Does Ap 1 have Life Insurance?*	YesNo
Has Ap 1 ever filed bankruptcy?*	YesNo
Please note any form of government assistance Ap 1 has received within the last 5 years
Ap 1 Bankruptcy Details*	*

Prospective Adoptive Parent 2 Work

Ap 2 Employer

If you are employed outside of the home, when did you become employed at your current job?*

Ap 2 Occupation/Title*

Ap 2 Work Street Address*

Ap 2 Work City*

Ap 2 Work State/Region*

Enter Region

Ap 2 Work Zip Code*

Ap 2 Work Phone*

()-ext

Enter Int'l Number

Prospective Adoptive Parent 2 Finances
Ap 2 Annual Income*	$*
Ap 2 Other Annual Income
Does Ap 2 have Life Insurance?*	YesNo*
Has Ap 2 ever filed bankruptcy?*	YesNo*
Please note any form of government assistance Ap 2 has received within the last 5 years
Ap 2 Bankruptcy Details*	*

Family Financial Information
Family Assets*	$
Family Liabilities*	$

If you list any significant medical or mental health issues, please provide a letter from your doctor. This letter should be forwarded to MAA as soon as possible after submitting your application so we can thoroughly review for program fit. The letter should be on doctor's letterhead, dated, state how long you have been under the doctor's care, what the diagnosis is, what the treatment is, and what the prognosis is. The letter should also conclude with whether or not the doctor believes the particular medical condition will have a negative impact on your ability to parent an adopted child. And should be notarized, if possible.

Prospective Adoptive Parent 1 Health
Ap 1 Health Status*
Ap 1 Height*
Enter in inches (in)
Ap 1 Weight*
Enter in pounds (lbs)
Ap 1's Health Insurance Covers Adopted Child*	YesNo

Prospective Adoptive Parent 2 Health
Ap 2 Health Status
Ap 2 Height*	*
Enter in inches (in)
Ap 2 Weight*	*
Enter in pounds (lbs)
Ap 2's Health Insurance Covers Adopted Child*	YesNo*

Medical Conditions

Have you or any of your family members had any medical conditions?

Family Details - Medical Conditions

Medications

Family Details - Medications

Criminal History
Have either prospective adoptive parent ever been arrested, charged, or convicted of any crimes, or spent jail time, including but not limited to, shoplifting, fraud, theft, prostitution, solicitation, DUI, DWI, domestic violence, child abuse, assault, or possession of a controlled substance? (Regardless if expunged, record sealed, etc.) If yes, please describe each occurrence in detail below, including dates.
Has Ap 1 ever been arrested for or accused of child abuse?*	YesNo
Has Ap 2 ever been arrested for or accused of child abuse?*	YesNo*
Has Ap 1 ever been arrested, charged or convicted of any crimes?*
YesNo
Has Ap 2 ever been arrested, charged or convicted of any crimes?*
YesNo*
If the answer to any of these questions is Yes, please provide a detailed explanation of each occurrence, including dates.*	*

Arrest/Conviction Record

Family Details - Arrest/Conviction Record

Children, Other Adults, or Any Other Person Living in the Home

Enter all persons (living) in home except Prospective Adoptive Parents.

Persons in Family Home

Minor or Adult Children Not Living in the Home

Enter any minor or adult children (living) not in home.

Adult Children Not in Home

Adoption Information
Are you pregnant?*	YesNo
Are you attempting to become pregnant or attempting to expand your family in any other way?*	YesNo

Home Study Agency

PLEASE NOTE:

The home study agency you choose MUST be Hague Accredited

Your home study MUST be completed by an agency employee, and NOT a contract worker

You MUST complete an International Adoption Home Study in order to proceed with this adoption

Gladney must review and approve your home study

If you are outside of Gladney’s home study service zone, and are still in the process of choosing a home study agency that meets the above criteria, please simply list ‘undecided’ in the text fields, and 00 in the number fields. Please contact us if you require guidance on choosing a home study agency that meets the requirements!

Home Study Agency Name*

Home Study Agency Address*

Home Study Agency City*

Home Study Agency State*

Enter Region

Enter your State of Residence if you do not have a Home Study Agency as of yet

Home Study Agency Zip*

Home Study Agency Phone*

()-ext

Enter Int'l Number

Home Study Agency Contact*

Home Study Agency Contact Email Address*

Expected Completion*

For families applying for the Ecuador program:
I understand that I am bound by confidentiality in regard to any child's file that I review.
I agree not to copy, duplicate, print, and/or share the file/photos/videos with anyone except for professionals (such as doctors, therapists, etc) who can evaluate the child and provide guidance on moving forward with the adoption of the child.

For families applying for Philippines and Thailand traditional/referral programs:
I understand that I am not guaranteed a spot in the quota for a particular year by applying, and that quota spots are designated for families upon submission of a completed dossier ready to submit to Thailand/the Philippines.

Completed Application
Once you have completed all fields on this form, please check this box and click submit*

Statement of Understanding
	I/we affirm that by submitting this adoption application, the information provided is true and accurate. I/we further understand that Gladney Center for Adoption retains the right to accept or refuse any application. Failure to provide accurate information or to withhold information may result in the termination of services at any time. Additionally, I/we understand that approval of this application does not guarantee approval of a home study or the placement of a child. The application fee is $600 for new clients, or $350 for returning placement clients, and is non-refundable. The following payment options are available: Pay online via PayPal (a link will be provided in an email after submission of the application) Mail a check made payable to: Gladney Center for Adoption. Please indicate “Application Fee” in the Memo section of your check. Mail to: 1102 Society Drive, Claymont, DE 19703. PLEASE NOTE: Your application cannot be processed until BOTH the online application AND fee are received by Gladney Center for Adoption. A member of our team will then begin processing your application. FOR NEW YORK FAMILIES ONLY, this form is a PRE-application. Once this initial form is reviewed, approved and accepted, each prospective adoptive applicant will need to fill out our New York specific application which will be forwarded to your designated email address. We are honored and excited to walk through this adoption journey with you!*

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Submitting...

Phone: 302-475-8977
Fax: 302-529-1976

Address:
Society Office Complex
1102 Society Drive
Claymont, DE 19703

E-mail:
contact@madisonadoption.org

	First Name*	Middle Name	Last Name*	Birth Date*	Gender*
	*		*	*	*

	First Name*	Middle Name	Last Name*	Birth Date*	Gender*
	*		*	*	*

	First Name*	Middle Name	Last Name*	Birth Date*	Gender*
	*		*	*	*

	First Name*	Middle Name	Last Name*	Birth Date*	Gender*
	*		*	*	*

	First Name*	Middle Name	Last Name*	Birth Date*	Gender*
	*		*	*	*

	Prospective Adoptive Parent*	Medication Name*	Reason for Medication*
	*	*	*

	First Name	Middle Name	Last Name	Birth Date	Relationship to Family	If Adopted Child, Country Adopted From