Gladney Center for Adoption | Prospective Adoptive Parents - Waiting Child Review Form

Dear Prospective Adoptive Parent, 

Prior to starting the adoption process, Gladney Center for Adoption, in partnership with Madison Adoption Associates, requires that a family submit a Prospective Adoptive Parents Form.  We really appreciate your time in telling us about your family.  All of this information will remain secure and confidential.  The purpose of this form is to make sure your family qualifies for the country program in which you are interested.  An Adoption Specialist will follow up with you after receiving your information.  We look forward to working with you and getting to know your family!

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.

 

Prospective Adoptive Parent 1 Ap 1 First Name* Ap 1 Last Name* Ap 1 Date of Birth* Ap 1 Birthplace (City, State, Country) Birth Country United States Australia Bulgaria Cambodia Canada China Colombia Dominican Republic Ecuador Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Thailand Ukraine United Kingdom Show All Countries PLEASE NOTE: If you were born outside of the US, you will be required to obtain a newly issued certified birth certificate from that country as part of your adoption process. Ap 1 Citizenship* United States Australia Bulgaria Cambodia Canada China Colombia Dominican Republic Ecuador Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Thailand Ukraine United Kingdom Show All Countries Ap 1 Education Level* High School Diploma GED Some College Associates Degree Bachelors Degree Masters Degree Doctoral Degree Postdoctoral Degree Juris Doctorate Degree Professional/Vocational   Ap 1 Religion (required for Philippines Program) Christian Agnostic Amish Atheist Baptist Buddhist Catholic Episcopalian Hindu Islam Jewish Latter Day Saints Lutheran Mennonite Methodist No Religion Non-Denominational Presbyterian Scientoligy Seventh Day Advantist   Ap 1 Active Church Member (required for Philippines Program) YesNo How long have you been an Active Church Member? (required for Philippines Program) Ap 1 Occupation/Title* Ap 1 Annual Income* $ Has Ap 1 ever been arrested, charged or convicted of any crimes?* YesNo If Yes, please explain in detail. If history of multiple occurrences, please explain each, including dates and any jail time.* * Ap 1 Health Status* Excellent Good Fair Poor Healthy   Ap 1 - For any previous/current health conditions (including but not limited to: cancer, transplant, syndrome, heart disease, etc), please provide details explaining diagnosis, prognosis, treatment, life expectancy, and effect on daily life.* Gender Assigned at Birth* Female Male   Ap 1 Height* Enter in inches (in) Ap 1 Weight* Enter in pounds (lbs) Ap 1 Is Taking Drugs/Medications* YesNo Ap 1 Drugs/Medications Details* * Ap 1 - Do you have a history of: counseling, trauma, mental health diagnosis, substance abuse, or grief/loss? Have you ever been prescribed medication to treat psychological conditions?* YesNo Ap 1 - If you answered yes to the above question, please explain:* * Ap 1 - Have you been hospitalized due to a psychological condition or change in psychiatric medicine?* YesNo Ap 1 - If yes for hospitalization or change in psychiatric medicine, please explain:* * Ap 1 - Do you currently, or have you previously, had any addiction? I understand that the regular use of substances, even if not an addiction, or if legal in my state, could result in the denial of our application by the country’s Central Authority.* YesNo Ap 1 - If you answered yes for addiction(s), please explain:* * Ap 1 - Have any children in your care ever been removed, voluntarily or involuntarily, from your home?* YesNo Ap 1 - If any children in your care have ever been removed from your home, please explain. Also, please note that you will be required to submit legal documentation related to the removal of the child(ren) with your application.* * Ap 1 - Have you ever been under investigation by child protective services (regardless of whether or not the investigation was founded)?* YesNo Ap 1 - If Yes, please explain in detail.* * Ap 1: Number of Prior Divorces* Ap 1: Date of Most Recent Divorce* * Family Marital Status* Divorced Married Single Widowed   If married, Date of Marriage* * Street Address* City* State/Region* AK - Alaska AL - Alabama AR - Arkansas AZ - Arizona CA - California CO - Colorado CT - Connecticut DC - District of Columbia DE - Delaware FL - Florida FM - Federated States of Micronesia GA - Georgia GU - Guam HI - Hawaii IA - Iowa ID - Idaho IL - Illinois IN - Indiana KS - Kansas KY - Kentucky LA - Louisiana MA - Massachusetts MD - Maryland ME - Maine MH - Marshall Islands MI - Michigan MN - Minnesota MO - Missouri MP - Northern Mariana Islands MS - Mississippi MT - Montana NC - North Carolina ND - North Dakota NE - Nebraska NH - New Hampshire NJ - New Jersey NM - New Mexico NV - Nevada NY - New York OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania PR - Puerto Rico PW - Palau RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VA - Virginia VI - Virgin Islands VT - Vermont WA - Washington WI - Wisconsin WV - West Virginia WY - Wyoming Enter Region Zip Code* Home Phone Number* ()-ext Enter Int'l Number Do you currently live outside of the US?* YesNo If you live outside of the US, please list your address* * Have you identified a placing agency?* YesNo Family Financial Information Family Assets* $ Family Liabilities* $ Family Net Worth* $ Auto-Calculated

Prospective Adoptive Parent 2 Ap 2 First Name Ap 2 Last Name* * Ap 2 Date of Birth* * Ap 2 Birthplace (City, State, Country) Birth Country United States Australia Bulgaria Cambodia Canada China Colombia Dominican Republic Ecuador Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Thailand Ukraine United Kingdom Show All Countries PLEASE NOTE: If you were born outside of the US, you will be required to obtain a newly issued certified birth certificate from that country as part of your adoption process. Ap 2 Citizenship* United States Australia Bulgaria Cambodia Canada China Colombia Dominican Republic Ecuador Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Thailand Ukraine United Kingdom * Show All Countries Ap 2 Education Level* High School Diploma GED Some College Associates Degree Bachelors Degree Masters Degree Doctoral Degree Postdoctoral Degree Juris Doctorate Degree Professional/Vocational *  Ap 2 Religion (required for Philippines Program) Christian Agnostic Amish Atheist Baptist Buddhist Catholic Episcopalian Hindu Islam Jewish Latter Day Saints Lutheran Mennonite Methodist No Religion Non-Denominational Presbyterian Scientoligy Seventh Day Advantist   Ap 2 Active Church Member (required for Philippines Program) YesNo How long have you been an Active Church Member? (required for Philippines Program) Ap 2 Occupation/Title* * Ap 2 Annual Income* $* Has Ap 2 ever been arrested, charged or convicted of any crimes?* YesNo* If Yes, please explain in detail. If history of multiple occurrences, please explain each, including dates and any jail time.* * Ap 2 Health Status* Excellent Good Fair Poor Healthy *  Ap 2 - For any previous/current health conditions (including but not limited to: cancer, transplant, syndrome, heart disease, etc), please provide details explaining diagnosis, prognosis, treatment, life expectancy, and effect on daily life.* * Gender Assigned at Birth* Female Male *  Ap 2 Height* * Enter in inches (in) Ap 2 Weight* * Enter in pounds (lbs) Ap 2 Is Taking Drugs/Medications* YesNo* Ap 2 Drugs/Medications Details* * Ap 2 - Do you have a history of: counseling, trauma, mental health diagnosis, substance abuse, or grief/loss? Have you ever been prescribed medication to treat psychological conditions?* YesNo* Ap 2 - If you answered yes to the above question, please explain:* * Ap 2 - Have you been hospitalized due to a psychological condition or change in psychiatric medicine?* YesNo* Ap 2 - If yes for hospitalization or change in psychiatric medicine, please explain:* * Ap 2 - Do you currently, or have you previously, had any addiction? I understand that the regular use of substances, even if not an addiction, or if legal in my state, could result in the denial of our application by the country’s Central Authority.* YesNo* Ap 2 - If you answered yes for addiction(s), please explain:* * Ap 2 - Have any children in your care ever been removed, voluntarily or involuntarily, from your home?* YesNo* Ap 2 - If any children in your care have ever been removed from your home, please explain. Also, please note that you will be required to submit legal documentation related to the removal of the child(ren) with your application.* * Ap 2 - Have you ever been under investigation by child protective services (regardless of whether or not the investigation was founded)?* YesNo* Ap 2 - If Yes, please explain in detail.* * Ap 2: Number of Prior Divorces* * Ap 2: Date of Most Recent Divorce* * Contacts Ap 1 Cell Phone* ()-ext Enter Int'l Number Ap 1 Email* Ap 2 Cell Phone* ()-ext * Enter Int'l Number Ap 2 Email* * Home Study Information Do you have a current, valid home study?* YesNo Home Study Agency Information* * Please list the agency who did your current home study HS Approval Date* * HS Approval Country Password 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.

Children in Home

# of children in home 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

	First Name	Last Name	Gender*	Birth Date*	If Adopted Child, Country Adopted From	Adoption Date
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Dominican Republic Ecuador Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Thailand Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Dominican Republic Ecuador Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Thailand Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Dominican Republic Ecuador Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Thailand Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Dominican Republic Ecuador Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Thailand Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Dominican Republic Ecuador Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Thailand Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Dominican Republic Ecuador Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Thailand Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Dominican Republic Ecuador Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Thailand Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Dominican Republic Ecuador Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Thailand Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Dominican Republic Ecuador Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Thailand Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Dominican Republic Ecuador Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Thailand Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Dominican Republic Ecuador Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Thailand Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Dominican Republic Ecuador Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Thailand Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Dominican Republic Ecuador Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Thailand Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Dominican Republic Ecuador Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Thailand Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Dominican Republic Ecuador Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Thailand Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Dominican Republic Ecuador Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Thailand Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Dominican Republic Ecuador Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Thailand Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Dominican Republic Ecuador Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Thailand Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Dominican Republic Ecuador Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Thailand Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Dominican Republic Ecuador Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Thailand Ukraine United Kingdom Show All Countries

Medical Conditions

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

Family Details - Medical Conditions 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

	For Whom*	Condition*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 *	Tuberculosis Tumor (non-cancerous) Cancer Heart Disease Liver Disease Neuropathy Genetic Disease Any Operations Diabetes Type I Diabetes Type II Alcoholism Substance Abuse Seizures Vision Impairments or Loss Hearing Impairments or Loss Mobility Impairments or Loss Herpes HIV Hepatitis A Hepatitis B Hepatitis C Other Communicable Disease Bi-Polar Disorder Eating Disorder Depression Anxiety Counseling/Therapy Other Asthma Thalassemia *

	For Whom*	Condition*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 *	Tuberculosis Tumor (non-cancerous) Cancer Heart Disease Liver Disease Neuropathy Genetic Disease Any Operations Diabetes Type I Diabetes Type II Alcoholism Substance Abuse Seizures Vision Impairments or Loss Hearing Impairments or Loss Mobility Impairments or Loss Herpes HIV Hepatitis A Hepatitis B Hepatitis C Other Communicable Disease Bi-Polar Disorder Eating Disorder Depression Anxiety Counseling/Therapy Other Asthma Thalassemia *

	For Whom*	Condition*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 *	Tuberculosis Tumor (non-cancerous) Cancer Heart Disease Liver Disease Neuropathy Genetic Disease Any Operations Diabetes Type I Diabetes Type II Alcoholism Substance Abuse Seizures Vision Impairments or Loss Hearing Impairments or Loss Mobility Impairments or Loss Herpes HIV Hepatitis A Hepatitis B Hepatitis C Other Communicable Disease Bi-Polar Disorder Eating Disorder Depression Anxiety Counseling/Therapy Other Asthma Thalassemia *

	For Whom*	Condition*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 *	Tuberculosis Tumor (non-cancerous) Cancer Heart Disease Liver Disease Neuropathy Genetic Disease Any Operations Diabetes Type I Diabetes Type II Alcoholism Substance Abuse Seizures Vision Impairments or Loss Hearing Impairments or Loss Mobility Impairments or Loss Herpes HIV Hepatitis A Hepatitis B Hepatitis C Other Communicable Disease Bi-Polar Disorder Eating Disorder Depression Anxiety Counseling/Therapy Other Asthma Thalassemia *

	For Whom*	Condition*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 *	Tuberculosis Tumor (non-cancerous) Cancer Heart Disease Liver Disease Neuropathy Genetic Disease Any Operations Diabetes Type I Diabetes Type II Alcoholism Substance Abuse Seizures Vision Impairments or Loss Hearing Impairments or Loss Mobility Impairments or Loss Herpes HIV Hepatitis A Hepatitis B Hepatitis C Other Communicable Disease Bi-Polar Disorder Eating Disorder Depression Anxiety Counseling/Therapy Other Asthma Thalassemia *

	For Whom*	Condition*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 *	Tuberculosis Tumor (non-cancerous) Cancer Heart Disease Liver Disease Neuropathy Genetic Disease Any Operations Diabetes Type I Diabetes Type II Alcoholism Substance Abuse Seizures Vision Impairments or Loss Hearing Impairments or Loss Mobility Impairments or Loss Herpes HIV Hepatitis A Hepatitis B Hepatitis C Other Communicable Disease Bi-Polar Disorder Eating Disorder Depression Anxiety Counseling/Therapy Other Asthma Thalassemia *

	For Whom*	Condition*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 *	Tuberculosis Tumor (non-cancerous) Cancer Heart Disease Liver Disease Neuropathy Genetic Disease Any Operations Diabetes Type I Diabetes Type II Alcoholism Substance Abuse Seizures Vision Impairments or Loss Hearing Impairments or Loss Mobility Impairments or Loss Herpes HIV Hepatitis A Hepatitis B Hepatitis C Other Communicable Disease Bi-Polar Disorder Eating Disorder Depression Anxiety Counseling/Therapy Other Asthma Thalassemia *

	For Whom*	Condition*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 *	Tuberculosis Tumor (non-cancerous) Cancer Heart Disease Liver Disease Neuropathy Genetic Disease Any Operations Diabetes Type I Diabetes Type II Alcoholism Substance Abuse Seizures Vision Impairments or Loss Hearing Impairments or Loss Mobility Impairments or Loss Herpes HIV Hepatitis A Hepatitis B Hepatitis C Other Communicable Disease Bi-Polar Disorder Eating Disorder Depression Anxiety Counseling/Therapy Other Asthma Thalassemia *

	For Whom*	Condition*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 *	Tuberculosis Tumor (non-cancerous) Cancer Heart Disease Liver Disease Neuropathy Genetic Disease Any Operations Diabetes Type I Diabetes Type II Alcoholism Substance Abuse Seizures Vision Impairments or Loss Hearing Impairments or Loss Mobility Impairments or Loss Herpes HIV Hepatitis A Hepatitis B Hepatitis C Other Communicable Disease Bi-Polar Disorder Eating Disorder Depression Anxiety Counseling/Therapy Other Asthma Thalassemia *

	For Whom*	Condition*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 *	Tuberculosis Tumor (non-cancerous) Cancer Heart Disease Liver Disease Neuropathy Genetic Disease Any Operations Diabetes Type I Diabetes Type II Alcoholism Substance Abuse Seizures Vision Impairments or Loss Hearing Impairments or Loss Mobility Impairments or Loss Herpes HIV Hepatitis A Hepatitis B Hepatitis C Other Communicable Disease Bi-Polar Disorder Eating Disorder Depression Anxiety Counseling/Therapy Other Asthma Thalassemia *

	For Whom*	Condition*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 *	Tuberculosis Tumor (non-cancerous) Cancer Heart Disease Liver Disease Neuropathy Genetic Disease Any Operations Diabetes Type I Diabetes Type II Alcoholism Substance Abuse Seizures Vision Impairments or Loss Hearing Impairments or Loss Mobility Impairments or Loss Herpes HIV Hepatitis A Hepatitis B Hepatitis C Other Communicable Disease Bi-Polar Disorder Eating Disorder Depression Anxiety Counseling/Therapy Other Asthma Thalassemia *

	For Whom*	Condition*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 *	Tuberculosis Tumor (non-cancerous) Cancer Heart Disease Liver Disease Neuropathy Genetic Disease Any Operations Diabetes Type I Diabetes Type II Alcoholism Substance Abuse Seizures Vision Impairments or Loss Hearing Impairments or Loss Mobility Impairments or Loss Herpes HIV Hepatitis A Hepatitis B Hepatitis C Other Communicable Disease Bi-Polar Disorder Eating Disorder Depression Anxiety Counseling/Therapy Other Asthma Thalassemia *

	For Whom*	Condition*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 *	Tuberculosis Tumor (non-cancerous) Cancer Heart Disease Liver Disease Neuropathy Genetic Disease Any Operations Diabetes Type I Diabetes Type II Alcoholism Substance Abuse Seizures Vision Impairments or Loss Hearing Impairments or Loss Mobility Impairments or Loss Herpes HIV Hepatitis A Hepatitis B Hepatitis C Other Communicable Disease Bi-Polar Disorder Eating Disorder Depression Anxiety Counseling/Therapy Other Asthma Thalassemia *

	For Whom*	Condition*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 *	Tuberculosis Tumor (non-cancerous) Cancer Heart Disease Liver Disease Neuropathy Genetic Disease Any Operations Diabetes Type I Diabetes Type II Alcoholism Substance Abuse Seizures Vision Impairments or Loss Hearing Impairments or Loss Mobility Impairments or Loss Herpes HIV Hepatitis A Hepatitis B Hepatitis C Other Communicable Disease Bi-Polar Disorder Eating Disorder Depression Anxiety Counseling/Therapy Other Asthma Thalassemia *

	For Whom*	Condition*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 *	Tuberculosis Tumor (non-cancerous) Cancer Heart Disease Liver Disease Neuropathy Genetic Disease Any Operations Diabetes Type I Diabetes Type II Alcoholism Substance Abuse Seizures Vision Impairments or Loss Hearing Impairments or Loss Mobility Impairments or Loss Herpes HIV Hepatitis A Hepatitis B Hepatitis C Other Communicable Disease Bi-Polar Disorder Eating Disorder Depression Anxiety Counseling/Therapy Other Asthma Thalassemia *

	For Whom*	Condition*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 *	Tuberculosis Tumor (non-cancerous) Cancer Heart Disease Liver Disease Neuropathy Genetic Disease Any Operations Diabetes Type I Diabetes Type II Alcoholism Substance Abuse Seizures Vision Impairments or Loss Hearing Impairments or Loss Mobility Impairments or Loss Herpes HIV Hepatitis A Hepatitis B Hepatitis C Other Communicable Disease Bi-Polar Disorder Eating Disorder Depression Anxiety Counseling/Therapy Other Asthma Thalassemia *

	For Whom*	Condition*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 *	Tuberculosis Tumor (non-cancerous) Cancer Heart Disease Liver Disease Neuropathy Genetic Disease Any Operations Diabetes Type I Diabetes Type II Alcoholism Substance Abuse Seizures Vision Impairments or Loss Hearing Impairments or Loss Mobility Impairments or Loss Herpes HIV Hepatitis A Hepatitis B Hepatitis C Other Communicable Disease Bi-Polar Disorder Eating Disorder Depression Anxiety Counseling/Therapy Other Asthma Thalassemia *

	For Whom*	Condition*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 *	Tuberculosis Tumor (non-cancerous) Cancer Heart Disease Liver Disease Neuropathy Genetic Disease Any Operations Diabetes Type I Diabetes Type II Alcoholism Substance Abuse Seizures Vision Impairments or Loss Hearing Impairments or Loss Mobility Impairments or Loss Herpes HIV Hepatitis A Hepatitis B Hepatitis C Other Communicable Disease Bi-Polar Disorder Eating Disorder Depression Anxiety Counseling/Therapy Other Asthma Thalassemia *

	For Whom*	Condition*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 *	Tuberculosis Tumor (non-cancerous) Cancer Heart Disease Liver Disease Neuropathy Genetic Disease Any Operations Diabetes Type I Diabetes Type II Alcoholism Substance Abuse Seizures Vision Impairments or Loss Hearing Impairments or Loss Mobility Impairments or Loss Herpes HIV Hepatitis A Hepatitis B Hepatitis C Other Communicable Disease Bi-Polar Disorder Eating Disorder Depression Anxiety Counseling/Therapy Other Asthma Thalassemia *

	For Whom*	Condition*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 *	Tuberculosis Tumor (non-cancerous) Cancer Heart Disease Liver Disease Neuropathy Genetic Disease Any Operations Diabetes Type I Diabetes Type II Alcoholism Substance Abuse Seizures Vision Impairments or Loss Hearing Impairments or Loss Mobility Impairments or Loss Herpes HIV Hepatitis A Hepatitis B Hepatitis C Other Communicable Disease Bi-Polar Disorder Eating Disorder Depression Anxiety Counseling/Therapy Other Asthma Thalassemia *

Medications

Family Details - Medications 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

	Prospective Adoptive Parent*	Medication Name*	Reason for Medication*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent*	Medication Name*	Reason for Medication*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent*	Medication Name*	Reason for Medication*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent*	Medication Name*	Reason for Medication*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent*	Medication Name*	Reason for Medication*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent*	Medication Name*	Reason for Medication*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent*	Medication Name*	Reason for Medication*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent*	Medication Name*	Reason for Medication*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent*	Medication Name*	Reason for Medication*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent*	Medication Name*	Reason for Medication*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent*	Medication Name*	Reason for Medication*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent*	Medication Name*	Reason for Medication*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent*	Medication Name*	Reason for Medication*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent*	Medication Name*	Reason for Medication*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent*	Medication Name*	Reason for Medication*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent*	Medication Name*	Reason for Medication*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent*	Medication Name*	Reason for Medication*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent*	Medication Name*	Reason for Medication*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent*	Medication Name*	Reason for Medication*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent*	Medication Name*	Reason for Medication*
	Prospective Adoptive Parent 1 Prospective Adoptive Parent 2 Prospective Adoptive Parents *	*	*

Madison Adoption Programs What Madison Adoption Programs are you interested in? (can check more than one)* Bulgaria China Colombia Dominican Republic Ecuador Hong Kong Philippines Thailand United States - Domestic Identified Domestic - Foster Care / SWAN Services (PA Families Only) Home Study Services Hosting Reverse Hosting Post Adoption/Placement Services Only Taiwan   Specific Child Information Child’s Name Listing child(ren) on this application does not necessarily hold the child(ren) for you. Please talk to our staff with any questions you might have. Child Date of Birth Adoptive Child Parameters Please note that all children adopted internationally will have some level of special needs. Those special needs are not always medical, but can also include history of trauma, neglect, and abuse; delays associated with institutionalization; parental history of mental health diagnoses; pre-natal exposure; and more. Please indicate below the areas that you would like to learn more about, and please know that we are available to discuss each category more in depth to provide you with a better understanding of the available children and their needs. Your indication of areas of interest in no way predetermine the needs of the child you will be matched to. You will also be given the opportunity to explore your parameters in depth during the home study process. Child Gender Preference* Either Female Only Female Preferred Male Only Male Preferred   Child Pref Age Range* Birth to 5 years old 5 to 10 years old 10 years and older   Child Parameters Memo Please list any additional needs your family would be open to as well as any information that will be helpful for us to find an appropriate match for your family. Do you acknowledge and understand that any child may have undiagnosed or undisclosed special needs?* YesNo Open to learning more about:* Minor/correctable needs Moderate needs Significant needs Cognitive delays History of physical abuse History of sexual abuse Older child Sibling group   Please indicate how you learned of Gladney and/or the specific child that you are inquiring about:* Agency recommendation Facebook – MAA main page Facebook – MAA waiting child group Facebook – other Instagram – MAA account Instagram – other Internet search MAA blog MAA Constant Contact email MAA website Other Rainbow Kids Reece’s Rainbow RODS Heroes The Shepherd’s Crook TikTok Word of mouth YouTube   Please feel free to expound upon how you heard of Gladney:

Completed Prospective Adoptive Parent Form Once you have completed all fields on this form, please check this box and click submit*

Should you be interested in working with our agency, 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 after we receive your adoption application and initial application fee. 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.

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If you have any problems with this form, please call MAA at (302) 475-8977.