Prospective Adoptive Parent Information Form

Dear Prospective Adoptive Parent,

Prior to starting the adoption process, MAA requires that a family submit a Prospective Adoptive Parent 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!

Prospective Adoptive Father (PAF) PAF Legal First Name Please leave blank if applying as a Single Woman PAF Legal Last Name* * PAF Legal Middle Name Nick Name Gender* Male Female * PAF Date of Birth* * Birth Country* United States Australia Cambodia Canada China Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Russia Sweden Switzerland Ukraine United Kingdom * Show All Countries PAF Citizenship* United States Australia Cambodia Canada China Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Russia Sweden Switzerland Ukraine United Kingdom * Show All Countries PAF Cell Phone* ()-ext * Enter Int'l Number PAF Email* * PAF Preferred Method of Contact* Cell Phone Home Email Home Phone Other Phone Work Email Work Phone *  Marital Information Marital Status* Divorced Married Single Widowed   If married, Date of Marriage* * Location of Marriage* * PAF Number of Prior Divorces* PAM Number of Prior Divorces* Contact Preferred Contact Method* Home Phone Home Email Ap 1 Email Ap 2 Email Ap 1 Work Email Ap 2 Work Email Ap 1 Cell Phone Ap 2 Cell Phone Ap 1 Work Phone Ap 2 Work Phone   Home Phone* ()-ext Enter Int'l Number Home Email* Fax Number ()-ext Enter Int'l Number Religion Madison Adoption Associates is committed to providing an environment that is free from discrimination.  Madison Adoption Associates 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. PAF Religion* 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 *  PAM Religion* 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   If Applicants have different religions, what religion would child be reared?* PAF Amount of Religious Involvement* > Once a Week Every once in a while Not Applicable Weekly *  PAM Amount of Religious Involvement* > Once a Week Every once in a while Not Applicable Weekly   Previous Home Study 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?

Prospective Adoptive Mother (PAM) PAM Legal First Name* PAM Legal Last Name* PAM Legal Middle Name Nick Name Gender* Male Female PAM Date of Birth* Birth Country* United States Australia Cambodia Canada China Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Russia Sweden Switzerland Ukraine United Kingdom Show All Countries PAM Citizenship* United States Australia Cambodia Canada China Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Russia Sweden Switzerland Ukraine United Kingdom Show All Countries PAM Cell Phone* ()-ext Enter Int'l Number PAM Email* PAM Preferred Method of Contact* Cell Phone Home Email Home Phone Other Phone Work Email Work Phone   Family Address Street Address* Street Address Line 2 City* State/Region* AK - Alaska AL - Alabama AR - Arkansas AS - American Samoa 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* 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 AK - Alaska AL - Alabama AR - Arkansas AS - American Samoa 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 Shipping Zip Code Shipping Country United States Australia Cambodia Canada China Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Russia Sweden Switzerland Ukraine United Kingdom 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). Photo Upload #1* Please upload a Family Picture Photo Upload #2 Please upload a Passport Style photo for MR. Applicant Photo Upload #3 Please upload a Passport Style photo for MRS/MS applicant. 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, and one number.

Education

	PAF Highest Level of Education	PAM Highest Level of Education*
	High School Diploma/GED Some College Associates Degree Masters Degree Bachelors Degree Doctoral Degree Postdoctoral Degree Professional/Vocational Juris Doctorate Degree *	High School Diploma/GED Some College Associates Degree Masters Degree Bachelors Degree Doctoral Degree Postdoctoral Degree Professional/Vocational Juris Doctorate Degree

If you list any medical issues or mental health issues, please provide a letter from doctor. (Other than tonsils, appendix, dental, vision, cosmetic, pregnancy, allergies)

Prospective Adoptive Father Health PAF Health Status* Excellent Good Fair Poor Healthy *  PAF Height* * Enter in inches (in) PAF Weight* * Enter in pounds (lbs) PAF's Health Insurance Covers Adopted Child* YesNo*

Prospective Adoptive Mother Health PAM Health Status* Excellent Good Fair Poor Healthy   PAM Height* Enter in inches (in) PAM Weight* Enter in pounds (lbs) PAM's Health Insurance Covers Adopted Child* YesNo

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 Father Prospective Adoptive Mother *	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 Father Prospective Adoptive Mother *	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 Father Prospective Adoptive Mother *	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 Father Prospective Adoptive Mother *	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 Father Prospective Adoptive Mother *	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 Father Prospective Adoptive Mother *	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 Father Prospective Adoptive Mother *	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 Father Prospective Adoptive Mother *	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 Father Prospective Adoptive Mother *	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 Father Prospective Adoptive Mother *	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 Father Prospective Adoptive Mother *	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 Father Prospective Adoptive Mother *	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 Father Prospective Adoptive Mother *	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 Father Prospective Adoptive Mother *	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 Father Prospective Adoptive Mother *	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 Father Prospective Adoptive Mother *	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 Father Prospective Adoptive Mother *	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 Father Prospective Adoptive Mother *	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 Father Prospective Adoptive Mother *	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 Father Prospective Adoptive Mother *	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 Father Prospective Adoptive Mother Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent	Medication Name	Reason for Medication
	Prospective Adoptive Father Prospective Adoptive Mother Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent	Medication Name	Reason for Medication
	Prospective Adoptive Father Prospective Adoptive Mother Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent	Medication Name	Reason for Medication
	Prospective Adoptive Father Prospective Adoptive Mother Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent	Medication Name	Reason for Medication
	Prospective Adoptive Father Prospective Adoptive Mother Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent	Medication Name	Reason for Medication
	Prospective Adoptive Father Prospective Adoptive Mother Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent	Medication Name	Reason for Medication
	Prospective Adoptive Father Prospective Adoptive Mother Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent	Medication Name	Reason for Medication
	Prospective Adoptive Father Prospective Adoptive Mother Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent	Medication Name	Reason for Medication
	Prospective Adoptive Father Prospective Adoptive Mother Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent	Medication Name	Reason for Medication
	Prospective Adoptive Father Prospective Adoptive Mother Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent	Medication Name	Reason for Medication
	Prospective Adoptive Father Prospective Adoptive Mother Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent	Medication Name	Reason for Medication
	Prospective Adoptive Father Prospective Adoptive Mother Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent	Medication Name	Reason for Medication
	Prospective Adoptive Father Prospective Adoptive Mother Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent	Medication Name	Reason for Medication
	Prospective Adoptive Father Prospective Adoptive Mother Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent	Medication Name	Reason for Medication
	Prospective Adoptive Father Prospective Adoptive Mother Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent	Medication Name	Reason for Medication
	Prospective Adoptive Father Prospective Adoptive Mother Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent	Medication Name	Reason for Medication
	Prospective Adoptive Father Prospective Adoptive Mother Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent	Medication Name	Reason for Medication
	Prospective Adoptive Father Prospective Adoptive Mother Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent	Medication Name	Reason for Medication
	Prospective Adoptive Father Prospective Adoptive Mother Prospective Adoptive Parents *	*	*

	Prospective Adoptive Parent	Medication Name	Reason for Medication
	Prospective Adoptive Father Prospective Adoptive Mother Prospective Adoptive Parents *	*	*

Prospective Adoptive Father Work PAF Employer* * If you are employed outside of the home, when did you become employed at your current job?* * PAF Occupation/Title* * PAF Work Street Address* * PAF Work City* * PAF Work State/Region* AK - Alaska AL - Alabama AR - Arkansas AS - American Samoa 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 PAF Work Zip Code* * PAF Work Phone* ()-ext * Enter Int'l Number Prospective Adoptive Father Finances PAF Annual Income* $* PAF Other Annual Income Does PAF have Life Insurance?* YesNo* Has PAF ever filed bankruptcy?* YesNo* Please note any form of government assistance PAF has received within the last 5 years. Cash Food Stamps Other Government Benefit Unemployment WIC   PAF Bankrupcy Details

Prospective Adoptive Mother Work PAM Employer* If you are employed outside of the home, when did you become employed at your current job?* PAM Occupation/Title* PAM Work Street Address* PAM Work City* PAM Work State/Region* AK - Alaska AL - Alabama AR - Arkansas AS - American Samoa 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 PAM Work Zip Code* PAM Work Phone* ()-ext Enter Int'l Number Prospective Adoptive Mother Finances PAM Annual Income* $ PAM Other Annual Income Does PAM have Life Insurance?* YesNo Has PAM ever filed bankruptcy?* YesNo Please note any form of government assistance PAM has received within the last 5 years. Cash Food Stamps Other Government Benefit Unemployment WIC   PAM Bankrupcy Details Family Financial Information Family Assets* $ Family Liabilities* $

Criminal History Have either prospective adoptive parent has ever been arrested, charged, or convicted of any crimes, 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 the details below. Has PAF ever been arrested for or accused of child abuse?* YesNo* Has PAM ever been arrested for or accused of child abuse?* YesNo Has PAF ever been arrested, charged or convicted of any crimes?* YesNo* Has PAM ever been arrested, charged or convicted of any crimes?* YesNo If the answer to any of these questions is Yes, please provide a brief description.* *

Children and/or Other Adults Living in Home

Enter all persons (living) in home except Perspective Adoptive Father & Mother.

Persons in Family Home 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

	First Name	Middle Name	Last Name	Birth Date	Gender
	*		*	*	Male Female *

	Relationship to Family	If Adopted Child, Country Adopted From
	Adopted Brother Adopted Child Adopted Daughter Adopted Sister Adopted Son Adoptive Father Adoptive Mother Aunt Bio-Daughter Bio-Father Bio-Mother Bio-Son Brother Cousin Ex-Husband Ex-Wife Foster Child Friend Grandfather Grandmother Nephew Niece Other Parent Sister Step-Brother Stepchild Stepfather Stepmother Step-Sister Uncle *	United States Australia Cambodia Canada China Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Russia Sweden Switzerland Ukraine United Kingdom Show All Countries

	First Name	Middle Name	Last Name	Birth Date	Gender
	*		*	*	Male Female *

	Relationship to Family	If Adopted Child, Country Adopted From
	Adopted Brother Adopted Child Adopted Daughter Adopted Sister Adopted Son Adoptive Father Adoptive Mother Aunt Bio-Daughter Bio-Father Bio-Mother Bio-Son Brother Cousin Ex-Husband Ex-Wife Foster Child Friend Grandfather Grandmother Nephew Niece Other Parent Sister Step-Brother Stepchild Stepfather Stepmother Step-Sister Uncle *	United States Australia Cambodia Canada China Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Russia Sweden Switzerland Ukraine United Kingdom Show All Countries

	First Name	Middle Name	Last Name	Birth Date	Gender
	*		*	*	Male Female *

	Relationship to Family	If Adopted Child, Country Adopted From
	Adopted Brother Adopted Child Adopted Daughter Adopted Sister Adopted Son Adoptive Father Adoptive Mother Aunt Bio-Daughter Bio-Father Bio-Mother Bio-Son Brother Cousin Ex-Husband Ex-Wife Foster Child Friend Grandfather Grandmother Nephew Niece Other Parent Sister Step-Brother Stepchild Stepfather Stepmother Step-Sister Uncle *	United States Australia Cambodia Canada China Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Russia Sweden Switzerland Ukraine United Kingdom Show All Countries

	First Name	Middle Name	Last Name	Birth Date	Gender
	*		*	*	Male Female *

	Relationship to Family	If Adopted Child, Country Adopted From
	Adopted Brother Adopted Child Adopted Daughter Adopted Sister Adopted Son Adoptive Father Adoptive Mother Aunt Bio-Daughter Bio-Father Bio-Mother Bio-Son Brother Cousin Ex-Husband Ex-Wife Foster Child Friend Grandfather Grandmother Nephew Niece Other Parent Sister Step-Brother Stepchild Stepfather Stepmother Step-Sister Uncle *	United States Australia Cambodia Canada China Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Russia Sweden Switzerland Ukraine United Kingdom Show All Countries

	First Name	Middle Name	Last Name	Birth Date	Gender
	*		*	*	Male Female *

	Relationship to Family	If Adopted Child, Country Adopted From
	Adopted Brother Adopted Child Adopted Daughter Adopted Sister Adopted Son Adoptive Father Adoptive Mother Aunt Bio-Daughter Bio-Father Bio-Mother Bio-Son Brother Cousin Ex-Husband Ex-Wife Foster Child Friend Grandfather Grandmother Nephew Niece Other Parent Sister Step-Brother Stepchild Stepfather Stepmother Step-Sister Uncle *	United States Australia Cambodia Canada China Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Russia Sweden Switzerland Ukraine United Kingdom Show All Countries

	First Name	Middle Name	Last Name	Birth Date	Gender
	*		*	*	Male Female *

	Relationship to Family	If Adopted Child, Country Adopted From
	Adopted Brother Adopted Child Adopted Daughter Adopted Sister Adopted Son Adoptive Father Adoptive Mother Aunt Bio-Daughter Bio-Father Bio-Mother Bio-Son Brother Cousin Ex-Husband Ex-Wife Foster Child Friend Grandfather Grandmother Nephew Niece Other Parent Sister Step-Brother Stepchild Stepfather Stepmother Step-Sister Uncle *	United States Australia Cambodia Canada China Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Russia Sweden Switzerland Ukraine United Kingdom Show All Countries

	First Name	Middle Name	Last Name	Birth Date	Gender
	*		*	*	Male Female *

	Relationship to Family	If Adopted Child, Country Adopted From
	Adopted Brother Adopted Child Adopted Daughter Adopted Sister Adopted Son Adoptive Father Adoptive Mother Aunt Bio-Daughter Bio-Father Bio-Mother Bio-Son Brother Cousin Ex-Husband Ex-Wife Foster Child Friend Grandfather Grandmother Nephew Niece Other Parent Sister Step-Brother Stepchild Stepfather Stepmother Step-Sister Uncle *	United States Australia Cambodia Canada China Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Russia Sweden Switzerland Ukraine United Kingdom Show All Countries

	First Name	Middle Name	Last Name	Birth Date	Gender
	*		*	*	Male Female *

	Relationship to Family	If Adopted Child, Country Adopted From
	Adopted Brother Adopted Child Adopted Daughter Adopted Sister Adopted Son Adoptive Father Adoptive Mother Aunt Bio-Daughter Bio-Father Bio-Mother Bio-Son Brother Cousin Ex-Husband Ex-Wife Foster Child Friend Grandfather Grandmother Nephew Niece Other Parent Sister Step-Brother Stepchild Stepfather Stepmother Step-Sister Uncle *	United States Australia Cambodia Canada China Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Russia Sweden Switzerland Ukraine United Kingdom Show All Countries

	First Name	Middle Name	Last Name	Birth Date	Gender
	*		*	*	Male Female *

	Relationship to Family	If Adopted Child, Country Adopted From
	Adopted Brother Adopted Child Adopted Daughter Adopted Sister Adopted Son Adoptive Father Adoptive Mother Aunt Bio-Daughter Bio-Father Bio-Mother Bio-Son Brother Cousin Ex-Husband Ex-Wife Foster Child Friend Grandfather Grandmother Nephew Niece Other Parent Sister Step-Brother Stepchild Stepfather Stepmother Step-Sister Uncle *	United States Australia Cambodia Canada China Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Russia Sweden Switzerland Ukraine United Kingdom Show All Countries

	First Name	Middle Name	Last Name	Birth Date	Gender
	*		*	*	Male Female *

	Relationship to Family	If Adopted Child, Country Adopted From
	Adopted Brother Adopted Child Adopted Daughter Adopted Sister Adopted Son Adoptive Father Adoptive Mother Aunt Bio-Daughter Bio-Father Bio-Mother Bio-Son Brother Cousin Ex-Husband Ex-Wife Foster Child Friend Grandfather Grandmother Nephew Niece Other Parent Sister Step-Brother Stepchild Stepfather Stepmother Step-Sister Uncle *	United States Australia Cambodia Canada China Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Russia Sweden Switzerland Ukraine United Kingdom Show All Countries

	First Name	Middle Name	Last Name	Birth Date	Gender
	*		*	*	Male Female *

	Relationship to Family	If Adopted Child, Country Adopted From
	Adopted Brother Adopted Child Adopted Daughter Adopted Sister Adopted Son Adoptive Father Adoptive Mother Aunt Bio-Daughter Bio-Father Bio-Mother Bio-Son Brother Cousin Ex-Husband Ex-Wife Foster Child Friend Grandfather Grandmother Nephew Niece Other Parent Sister Step-Brother Stepchild Stepfather Stepmother Step-Sister Uncle *	United States Australia Cambodia Canada China Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Russia Sweden Switzerland Ukraine United Kingdom Show All Countries

	First Name	Middle Name	Last Name	Birth Date	Gender
	*		*	*	Male Female *

	Relationship to Family	If Adopted Child, Country Adopted From
	Adopted Brother Adopted Child Adopted Daughter Adopted Sister Adopted Son Adoptive Father Adoptive Mother Aunt Bio-Daughter Bio-Father Bio-Mother Bio-Son Brother Cousin Ex-Husband Ex-Wife Foster Child Friend Grandfather Grandmother Nephew Niece Other Parent Sister Step-Brother Stepchild Stepfather Stepmother Step-Sister Uncle *	United States Australia Cambodia Canada China Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Russia Sweden Switzerland Ukraine United Kingdom Show All Countries

	First Name	Middle Name	Last Name	Birth Date	Gender
	*		*	*	Male Female *

	Relationship to Family	If Adopted Child, Country Adopted From
	Adopted Brother Adopted Child Adopted Daughter Adopted Sister Adopted Son Adoptive Father Adoptive Mother Aunt Bio-Daughter Bio-Father Bio-Mother Bio-Son Brother Cousin Ex-Husband Ex-Wife Foster Child Friend Grandfather Grandmother Nephew Niece Other Parent Sister Step-Brother Stepchild Stepfather Stepmother Step-Sister Uncle *	United States Australia Cambodia Canada China Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Russia Sweden Switzerland Ukraine United Kingdom Show All Countries

	First Name	Middle Name	Last Name	Birth Date	Gender
	*		*	*	Male Female *

	Relationship to Family	If Adopted Child, Country Adopted From
	Adopted Brother Adopted Child Adopted Daughter Adopted Sister Adopted Son Adoptive Father Adoptive Mother Aunt Bio-Daughter Bio-Father Bio-Mother Bio-Son Brother Cousin Ex-Husband Ex-Wife Foster Child Friend Grandfather Grandmother Nephew Niece Other Parent Sister Step-Brother Stepchild Stepfather Stepmother Step-Sister Uncle *	United States Australia Cambodia Canada China Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Russia Sweden Switzerland Ukraine United Kingdom Show All Countries

	First Name	Middle Name	Last Name	Birth Date	Gender
	*		*	*	Male Female *

	Relationship to Family	If Adopted Child, Country Adopted From
	Adopted Brother Adopted Child Adopted Daughter Adopted Sister Adopted Son Adoptive Father Adoptive Mother Aunt Bio-Daughter Bio-Father Bio-Mother Bio-Son Brother Cousin Ex-Husband Ex-Wife Foster Child Friend Grandfather Grandmother Nephew Niece Other Parent Sister Step-Brother Stepchild Stepfather Stepmother Step-Sister Uncle *	United States Australia Cambodia Canada China Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Netherlands Russia Sweden Switzerland Ukraine United Kingdom Show All Countries

PAF Approved by Adoption Agency in Past Year Has PAF been approved by an adoption agency in the past year?* YesNo* If yes, please explain* * PAF Turned Down by Adoption Agency Has PAF ever been turned down for adoption by another agency?* YesNo* If Yes, please explain* *

PAM Approved by Adoption Agency in Past Year Has PAM been approved by an adoption agency in the past year?* YesNo If yes, please explain* * PAM Turned Down by Adoption Agency Has PAM ever been turned down for adoption by another agency? YesNo If Yes, please explain* *

I would like information on the following services: Please select the programs or services you are interested in.* China Special Needs Home Study Services Hosting Identified Domestic Adoption Services Philippines Post Adoption/Placement Services Only Waiting Child available through MAA   Specific Child Information Please indicate if you are inquiring about a child currently on Madison Adoption Associates Individual List. Child’s Name Child Date of Birth MAA Camp Baoan Trip - May 2013 BULGARIA Camp Dragon Camp Dragon 2 - Guangdong Camp Horse - March 2014 Camp Ox 11.09 - Xuxhou Camp Ox 2.09 - Tianjin Camp Ox 7.09 - Guangzhou Camp Rabbit 2 - Baoan Camp Rabbit Shanghai/Beijing Camp Snake - Gaozhou Camp Tiger - Longgang Camp Tiger 2 - Qingdao Guangxi - March 2012 Heilongjiang Referrals None PHILIPPINES Shanghai Camp Warming Hearts   Adoptive Child Preferences Child Gender Preference* Either Female Only Female Preferred Male Only Male Preferred None   Child Pref Min Age* 0 0.5 1 1.5 2 3 4 5 6 7 8 9 10 11 12 13 14 15   Child Pref Max Age* 0 0.5 1 1.5 2 3 4 5 6 7 8 9 10 11 12 13 14 15   Are you applying to adopt a child with special needs?* Yes No Undecided  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 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   Please indicate only the special needs that you would be confident in accepting in a child. For each condition marked, you are agreeing to fully research and educate yourselves about the condition, including contacting medical specialists to discuss treatment, risks and long-term effects. By selecting a special need condition you are authorizing MAA to match you with a child who has that condition. 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 Child Preference 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.

Comments How did you hear about us?* Adoptive Families Adoption Guide Adoptive Families Magazine Brittany's Hope Foundation Church Client Referral (please specify below) Focus on the Family Friend Google Search Home Study Provider In His Hands Internet reviews Love Without Boundaries (LWB) LPA MAA Blog MAA Facebook Page MAA Website Magazine MSN Search Newspaper Ad Other Pastor Placing Agency Radio Spot Rainbow Kids Reece's Rainbow Saw Building Sign Social Worker Television The Shepherds Crook Word of Mouth Yahoo Groups Yahoo! Search Yellow Pages   Please provide the name of the specific persons or places*

Completed Application Once you have completed all fields on this form, please check this box and click submit*

Statement of Understanding
	I affirm that by submitting this Prospective Adoptive Parents Form, the information provided is true and accurate.  I further understand that failure to provide accurate information or to withhold information may result in the termination of services at any time.  Additionally, I understand that approval of this application does not guarantee approval of a home study or the placement of a child. Prospective Adoptive Father Signature __________________________________________________________________________     Date _______________________________ Prospective Adoptive Mother Signature _________________________________________________________________________      Date _______________________________

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