Gladney Application for Home Study and/or Post-Placement / Post-Adoption Services ONLY

Dear Prospective Adoptive Parents,

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 us understand the unique circumstances of your desired adoption journey. This application is for Home Study and/or Post-Placement/Post-Adoption Services ONLY. Please complete if you are NOT using Gladney Center for Adoption for placement.

If you are using Gladney for your adoption placement, please STOP and fill out our Placement application here (You do not need to complete a separate application for your Home Study if you are using Gladney for placement services): Placement Application. If you are using Gladney for Home Study or Post- Placement/Post-Adoption Services only, please continue!

Upon completion of this application, please pay the application fee of $350. Gladney is licensed to conduct home studies in Arkansas, Delaware, Florida, Illinois, Missouri, New Jersey, New York, North Carolina, Oklahoma, Pennsylvania, and Texas. We are happy to refer you to a home study agency in your area, if needed. A list of our pre-approved Supervised Providers is available upon request.

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.

Please note that 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?

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*

Enter International

Prospective Adoptive Parent 1 Finances

Ap 1 Annual Income*

Ap 1 Other Annual Income

Does Ap 1 have Life Insurance?*

Yes

Has Ap 1 ever filed bankruptcy?*

Yes

Please note any form of government assistance Ap 1 has received within the last 5 years

Ap 1 Bankruptcy Details**

Family Financial Information

Family Assets*

Family Liabilities*

How do you plan to pay for adoption expenses?*

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**

Enter International

Prospective Adoptive Parent 2 Finances

Ap 2 Annual Income**

Ap 2 Other Annual Income

Does Ap 2 have Life Insurance?**

Yes

Has Ap 2 ever filed bankruptcy?**

Yes

Please note any form of government assistance Ap 2 has received within the last 5 years

Ap 2 Bankruptcy Details**

If you list any significant medical or mental health issues, please provide a letter from your doctor. This letter should be forwarded to Gladney 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 *

Ap 1 Weight *

Ap 1 Eye Color*

Ap 1 Hair Color*

Ap 1 Complexion*

Ap 1's Health Insurance Covers Adopted Child*

Yes

Prospective Adoptive Parent 2 Health

Ap 2 Health Status

Ap 2 Height **

Ap 2 Weight **

Ap 2 Eye Color**

Ap 2 Hair Color**

Ap 2 Complexion**

Ap 2's Health Insurance Covers Adopted Child**

Yes

Medical Conditions

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

Family Details - Medical Conditions

Medications

Family Details - Medications

Education

Ap 1 Education Level*

Ap 2 Education Level

Academic History

Enter information on the highest degree, diploma, or certificate earned for each applicant.

Family Details - Academic History

Employment History

Please list 10 years of employment history for each applicant.

Family Details - Employment History

Ap 1 or Ap 2*	Occupation*	Employer*	Employer Address*	Dates of Employment*	Gross Annual Income*

States/Countries of Residence Since 18 Years Old

If you are adopting internationally, please list your addresses from the age of 18 for each applicant. If you are adopting domestically, please list 10 years of address history for each applicant. Include international addresses, if applicable.

Previous Addresses

Siblings / Extended Family Members

Please list the family of origin, or anyone that was living in your home as a child/adolescent, for each applicant.

Extended Family Members

References

Please include 5 or 6 (if in NY) references. Please include one family member. For NY, there must be three references for each individual. If adopting from the Philippines, one of the references must be a religious official.

Family Details - References

Criminal History

Have either prospective adoptive parent has 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?*

Yes

Has Ap 2 ever been arrested for or accused of child abuse?**

Yes

Has Ap 1 ever been arrested, charged or convicted of any crimes?*

Yes

Has Ap 2 ever been arrested, charged or convicted of any crimes?**

Yes

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, and deceased children, if applicable.

Adult Children Not in Home

Adoption Information

Are you pregnant?*

Yes

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

Yes

Please indicate how important the following were in your decision to apply with us.

Decision to Apply

Our Staff/Professionalism

Our Costs

Our Home Study Packet

Our Information Packet

Our Website

Placing Agency

What Country are you adopting from?*

Name of Placing Agency you are working with*

Placing Agency Address

Placing Agency City

Placing Agency State/Region

Enter Region

Placing Agency Zip

Placing Agency Contact Name

Placing Agency Contact Email

Placing Agency Contact Phone Number

Enter International

Do you have a particular child identified?

DOB of child

How did you identify this child?

Statement of Understanding

I/we affirm that by submitting this application that the information provided is true and accurate. I/we further understand that failure to provide accurate information or to withhold information may result in the termination of services at any time. I/we understand that fees paid will not be refunded if it is determined that information was withheld or reported inaccurately on the application. I/we understand that Gladney has the right to accept or refuse my application based on review of the information submitted. Additionally, I/we understand that approval of this application does not guarantee approval of a home study or a placement of a child.

This application fee is $350 and is non-refundable.

The following payment options are available:

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

PLEASE NOTE: 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. 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.

We are honored and excited to walk through this adoption journey with you!

Submit