MAA Prospective Adoptive Parents - Waiting Child Review Form

Dear Prospective Adoptive Parent, 

Prior to starting the adoption process, 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.  A Madison Adoption Associate 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 woman, 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 Citizenship* United States Australia Bulgaria Cambodia Canada China Colombia Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Ukraine United Kingdom Show All Countries Ap 1 Education Level* High School Diploma/GED Some College Associates Degree Masters Degree Bachelors Degree Doctoral Degree Postdoctoral Degree Professional/Vocational Juris Doctorate Degree   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* * Ap 1 Health Status* Excellent Good Fair Poor Healthy   For any health condition, please provide details explaining diagnosis, prognosis, treatment, life expectancy and its potential effect on your ability to parent a child.* * Gender* 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 - Do you currently, or have you previously, had an addiction(s)?* 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:* * 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 Citizenship* United States Australia Bulgaria Cambodia Canada China Colombia Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Ukraine United Kingdom * Show All Countries Ap 2 Education Level* High School Diploma/GED Some College Associates Degree Masters Degree Bachelors Degree Doctoral Degree Postdoctoral Degree Professional/Vocational Juris Doctorate Degree *  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* * Ap 2 Health Status* Excellent Good Fair Poor Healthy *  For any health conditions, please provide a details explaining your diagnosis, prognosis, treatment, life expectancy and its potential effect on your ability to parent a child* * Gender* 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 - Do you currently, or have you previously, had an addiction(s)?* 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:* * 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, and one number.

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 Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland Ukraine United Kingdom Show All Countries
			Female Male		United States Australia Bulgaria Cambodia Canada China Colombia Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Philippines Russia Sweden Switzerland 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?* Bulgaria China Special Needs Colombia Dominican Republic Home Study Services Hosting Identified Domestic Adoption Services Philippines Post Adoption/Placement Services Only Reverse Hosting Waiting Child available through MAA   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 Preferences Child Gender Preference* Either Female Only Female Preferred Male Only Male Preferred None   Child Pref Age Range* Infant/Toddler (up to 3 years) Pre-School (3 - 6 years) Older (over 7 years)   Acceptable Special Needs:* Albinism Ambiguous Genitalia Amniotic Band Syndrome Anal Atresia / Imperforate Anus Birthmark Blind / Sight Impaired Burns / Scars Cerebral Palsy Cleft Lip / Palate Club Foot Deaf / Hearing Impaired Developmental Delays Diabetes Down Syndrome Dwarfism Eczema / Ichtyosis Epilepsy/Seizures Failure to Thrive Fetal Alcohol Effects Funnel / Pigeon Chest Heart Condition Hemophilia Hepatitis B Hepatitis C Hydrocephalus Hypospadia Including but not limited to Joint Disorder Limb Difference - Missing Limbs Limb Difference - Missing/Extra Digits Meningocele Mental Delays Nerve Disorder Premature Birth Spina Bifida Thalassemia Urinary / Reproductive System Disorder   Open to Siblings* YesNo Do you acknowledge and understand that any child may have undiagnosed or undisclosed special needs?* YesNo Will you accept a child who has more than one special need?* YesNo Please indicate how you learned of MAA and/or the specific child that you are inquiring about. Please be as detailed as possible!* For example, if you were led her via Facebook, please indicate where on Facebook (MAA page, blog post, a group, advocacy post, etc.).

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

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