Gladney Hosting Program Application

GLADNEY HOSTING PROGRAM APPLICATION

Gladney's Hosting Program is open to families that reside in Arkansas, Florida, Illinois,
Missouri, New Jersey, North Carolina, Oklahoma, Pennsylvania, and Texas. A full Hague compliant home study is required.

Upon successful submission of the application, you will be prompted to submit payment for the application fee of $200; this can be done via credit card or by sending in a check made payable to Gladney Center for Adoption. Please note that the application fee is a non-refundable payment and not a guarantee that you will be accepted into the Hosting Program.

Upon receipt and review of the application and fee, you will be contacted. Approved applicants will be provided with an information packet and required documentation.

Please contact hosting@gladney.org with any questions.

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 'Adoptive Parent 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?

Education

Ap 1 Education Level*

Ap 2 Education Level**

Academic History

Family Details - Academic History

Prospective Adoptive Parent*	Academic Institution*	Location*	Type of Degree*	Year of Completion*

PAP 1 Military Service/First Responder

Ap 1 Military Service

Ap 1 DD Form 214 Received

Ap 1 First Responder Job

Ap 1 Verified by Employment Letter

PAP 2 Military Service/First Responder

Ap 2 Military Service

Ap 2 DD Form 214 Received

Ap 2 First Responder Job

Ap 2 Verified by Employment Letter

Prospective Adoptive Parent 1 Work

Ap 1 Employer*

If you are employed outside of the home, when did you become employed at your current job?*

Ap 1 Occupation/Title*

Ap 1 Work Street Address*

Ap 1 Work City*

Ap 1 Work State/Region*

Enter Region

Ap 1 Work Zip Code*

Ap 1 Work Phone*

Enter International

Prospective Adoptive Parent 1 Finances

Ap 1 Annual Income*

Ap 1 Other Annual Income

Does Ap 1 have Life Insurance?*

Yes

Has Ap 1 ever filed bankruptcy?*

Yes

Please note any form of government assistance Ap 1 has received within the last 5 years

Ap 1 Bankruptcy Details**

Prospective Adoptive Parent 2 Work

Ap 2 Employer

If you are employed outside of the home, when did you become employed at your current job?**

Ap 2 Occupation/Title**

Ap 2 Work Street Address**

Ap 2 Work City**

Ap 2 Work State/Region**

Enter Region

Ap 2 Work Zip Code**

Ap 2 Work Phone**

Enter International

Prospective Adoptive Parent 2 Finances

Ap 2 Annual Income**

Ap 2 Other Annual Income

Does Ap 2 have Life Insurance?**

Yes

Has Ap 2 ever filed bankruptcy?**

Yes

Please note any form of government assistance Ap 2 has received within the last 5 years

Ap 2 Bankruptcy Details**

Family Financial Information

Family Assets*

Family Liabilities*

If you list any significant medical or mental health issues, please provide a letter from your doctor. This letter should be forwarded to Gladney as soon as possible after submitting your application so we can thoroughly review for program fit. The letter should be on doctor's letterhead, dated, state how long you have been under the doctor's care, what the diagnosis is, what the treatment is, and what the prognosis is. The letter should also conclude with whether or not the doctor believes the particular medical condition will have a negative impact on your ability to parent an adopted child. And should be notarized, if possible.

Prospective Adoptive Parent 1 Health

Ap 1 Health Status*

Ap 1 Height *

Ap 1 Weight *

Ap 1's Health Insurance Covers Adopted Child*

Yes

Prospective Adoptive Parent 2 Health

Ap 2 Health Status**

Ap 2 Height **

Ap 2 Weight **

Ap 2's Health Insurance Covers Adopted Child**

Yes

Medical Conditions

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

Family Details - Medical Conditions

Medications

Family Details - Medications

Criminal History

Have either prospective adoptive parent has ever been arrested, charged, or convicted of any crimes, or spent jail time, 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 each occurrence in detail below, including dates.

Has Ap 1 ever been arrested for or accused of child abuse?*

Yes

Has Ap 2 ever been arrested for or accused of child abuse?**

Yes

Has Ap 1 ever been arrested, charged or convicted of any crimes?*

Yes

Has Ap 2 ever been arrested, charged or convicted of any crimes?**

Yes

If the answer to any of these questions is Yes, please provide a detailed explanation of each occurrence, including dates.**

Arrest/Conviction Record

Family Details - Arrest/Conviction Record

Children and/or Other Adults Living in Home

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

Persons in Family Home

Adult Children Not in Home

Enter all adult children (living) not in home

Adult Children Not in Home

Program Information

Are you pregnant?

Yes

Are you attempting to become pregnant or attempting to expand your family in any other way?

Yes

Home Study Agency

PLEASE NOTE:

The home study agency you choose MUST be Hague Accredited

Your home study MUST be completed by an agency employee, and NOT a contract worker

You MUST complete an International Adoption Home Study in order to proceed with this adoption

Gladney must review and approve your home study

If you are outside of Gladney’s home study service zone, and are still in the process of choosing a home study agency that meets the above criteria, please simply list ‘undecided’ in the text fields, and 00 in the number fields. Please contact us if you require guidance on choosing a home study agency that meets the requirements!

Home Study Agency Name*

Home Study Agency Address*

Home Study Agency City*

Home Study Agency State *

Enter Region

Home Study Agency Zip*

Home Study Agency Phone*

Enter International

Home Study Agency Contact*

Home Study Agency Contact Email Address*

Expected Completion*

* Please answer the questions below thoroughly, as brief/incomplete answers will delay the processing of your application *

Questions for Family

What is your motivation to participate in the Hosting program?*

Are you interested in adopting a child or children? Why or why not?*

Have you ever adopted before? If yes, please list country, date, age and any special needs of child.*

Why do you feel like you would be a good fit for a Hosting placement?*

Describe your experience with children, particularly your experience with older children or children with special needs?*

What makes your family a good match for a child with special needs?*

What are your parenting strengths?*

What resources are available in your local area?

Does any household member have a history of domestic violence, child abuse, arrest or addiction? EVEN IF IT DID NOT RESULT IN AN ARREST OR CONVICTION?*

Hosting Program | Child Confidentiality Statement

I understand that I am bound by confidentiality in regard to any child's file that I review.*

I agree not to copy, duplicate, print, and/or share the file/photos/videos with anyone except for professionals (such as doctors, therapists, etc) who can evaluate the child and provide guidance on moving forward with participating in the program.*

Completed Application

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

Statement of Understanding

I/we affirm that by submitting this Hosting Program application, the information provided is true and accurate. I/we further understand that Gladney retains the right to accept or refuse any application. I/we further understand that failure to provide accurate information or to withhold information may result in the termination of services at any time. Additionally, I/we understand that approval of this application does not guarantee approval of a home study or participation in the program.

The Hosting Program application fee is $200 and is non-refundable.

The following payment options are available:

Pay Online (a link will be provided after the application has been submitted)
Mail a check made payable to: Gladney Center for Adoption. Please indicate “Hosting Program Application Fee” in the Memo section of your check. Mail to: 1102 Society Drive, Claymont, DE 19703

PLEASE NOTE: Your application cannot be processed until BOTH the online application AND fee are received by Gladney Center for Adoption. A member of our team will then begin reviewing and processing your application.

We are honored and excited to walk through this Hosting journey with you!

Gladney Center for Adoption

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