Madison Adoption Associates
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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.

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

Prospective Adoptive Parent 1

Ap 1 First Name*

Ap 1 Last Name*

Ap 1 Date of Birth*

Ap 1 Citizenship*

Show All Countries

Ap 1 Education Level*

Ap 1 Religion (required for Philippines Program)

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*

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*

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: Number of Prior Divorces*

Family

Marital Status*

If married, Date of Marriage*

*

Street Address*

City*

State/Region*

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*

*

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*

*	Show All Countries

Ap 2 Education Level*

*

Ap 2 Religion (required for Philippines Program)

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*

*

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*

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: Number of Prior Divorces*

*

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

Medical Conditions

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

Family Details - Medical Conditions

Medications

Family Details - Medications

Madison Adoption Programs
What Madison Adoption Programs are you interested in?*

Specific Child Information
Child’s Name
Child Date of Birth

Adoptive Child Preferences
Child Gender Preference*
Child Pref Age Range*
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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Submitting...

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

Phone: 302-475-8977
Fax: 302-529-1976

Address:
Society Office Complex
1102 Society Drive
Claymont, DE 19703

E-mail:
contact@madisonadoption.org

	Prospective Adoptive Parent*	Medication Name*	Reason for Medication*
	*	*	*