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, 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?

Yes, Login

No, Begin Form

Marital Information
Marital Status*

If married, Date of Marriage*
*
Location of Marriage*
*
Ap 1: Number of Prior Divorces*

Ap 2: Number of Prior Divorces*
*
Ap 1 Parental Rights Terminated*
YesNo
If yes, please explain*
*
Ap 2 Parental Rights Terminated*
YesNo*
If yes, please explain*
*

Religion
Gladney Center for Adoption is committed to providing an environment that is free from discrimination. Gladney 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 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
Which service are you applying for?*

Please explain if you chose 'Other' for HS Type*
*
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*
*
If the home study process was terminated, what was the reason for terminating the process?

Has your family disrupted or dissolved an adoption?*
YesNo
If yes, please explain (this will not automatically exclude you):*
*

Family Contact Information

Street Address*

Street Address Line 2

City*

State/Region*

Enter Region

Zip Code*

County

Country*

Show All Countries

Home Phone Number*

()-ext

Enter Int'l Number

Fax Number

()-ext

Enter Int'l Number

Choose State of Residence for Home Study*

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.

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*	$

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 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?*	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

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

()-ext

Enter Int'l Number

Do you have a particular child identified?

PLEASE NOTE: The home study is a clinical assessment of a prospective adoptive family. Gladney reserves the right to determine the parameters of the child, and number of children, that the PAP is ultimately approved for within the home study. If you intend to pursue a specific child(ren), please call Gladney prior to application submission to ensure there will be no delays in your home study process, and to determine if Gladney is able to serve as your home study provider. Also please understand that Gladney’s approval of your home study application and acceptance of your home study case is in no way a guarantee of a home study approval.

DOB of child

Please list the DOB of particular child interested in.

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!

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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

	For Whom*	Condition*
	*	*

	For Whom*	Condition*
	*	*