Prospective Adoptive Parent 1 |
Ap 1 First Name* |
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Ap 1 Last Name* |
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Ap 1 Date of Birth* |
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Ap 1 Citizenship* |
| Show All Countries |
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Ap 1 Education Level* |
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Ap 1 Religion (required for Philippines Program) |
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Ap 1 Active Church Member (required for Philippines Program) |
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How long have you been an Active Church Member? (required for Philippines Program) |
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Ap 1 Occupation/Title* |
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Ap 1 Annual Income* |
$ |
Has Ap 1 ever been arrested, charged or convicted of any crimes?* |
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If Yes, please explain in detail. If history of multiple occurrences, please explain each, including dates and any jail time.* |
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Ap 1 Health Status* |
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For any health condition, please provide details explaining diagnosis, prognosis, treatment, life expectancy and its potential effect on your ability to parent a child.* |
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Gender* |
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Ap 1 Height* |
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Enter in inches (in) |
Ap 1 Weight* |
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Enter in pounds (lbs) |
Ap 1 Is Taking Drugs/Medications* |
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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?* |
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Ap 1 - If you answered yes to the above question, please explain:* |
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Ap 1 - Do you currently, or have you previously, had an addiction(s)?* |
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Ap 1 - If you answered yes for addiction(s), please explain:* |
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Ap 1 - Have any children in your care ever been removed, voluntarily or involuntarily, from your home?* |
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Ap 1 - If any children in your care have ever been removed from your home, please explain:* |
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Ap 1: Number of Prior Divorces* |
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Ap 1: Date of Most Recent Divorce* |
* |
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Prospective Adoptive Parent 2 |
Ap 2 First Name |
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Ap 2 Last Name* |
* |
Ap 2 Date of Birth* |
* |
Ap 2 Citizenship* |
* | Show All Countries |
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Ap 2 Education Level* |
* |
Ap 2 Religion (required for Philippines Program) |
|
Ap 2 Active Church Member (required for Philippines Program) |
|
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?* |
* |
If Yes, please explain in detail. If history of multiple occurrences, please explain each, including dates and any jail time.* |
* |
Ap 2 Health Status* |
* |
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* |
* |
Ap 2 Height* |
* |
Enter in inches (in) |
Ap 2 Weight* |
* |
Enter in pounds (lbs) |
Ap 2 Is Taking Drugs/Medications* |
* |
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?* |
* |
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)?* |
* |
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?* |
* |
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* |
* |
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