Prospective Adoptive Parent 1 |
Ap 1 First Name* |
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Ap 1 Legal Middle Name |
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Ap 1 Last Name* |
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Ap 1 Name Prefix* |
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Nick Name |
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Gender Assigned at Birth* |
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Race* |
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Ap 1 Date of Birth* |
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Ap 1 Birthplace (City, State, Country)* |
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Birth Country* |
| Show All Countries |
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PLEASE NOTE: If you were born outside of the US, you will be required to obtain a newly issued certified birth certificate from that country as part of your adoption process. |
Ap 1 Citizenship* |
| Show All Countries |
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Ap 1 Cell Phone* |
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Ap 1 Email* |
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Ap 1 Preferred Contact Method* |
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Ap 1 Passport Number |
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Ap 1 - List States Previously Lived in since 18 years old (this includes other countries or states resided in for college/schooling)* |
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Ap 1 Dual Citizenship* |
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Countries where have Dual Citizenship for Ap 1* |
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Ap 1 - For any previous/current health conditions (including but not limited to: cancer, transplant, syndrome, heart disease, etc), please provide details explaining diagnosis, prognosis, treatment, life expectancy, and effect on daily life.* |
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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 - Have you been hospitalized due to a psychological condition or change in psychiatric medicine?* |
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Ap 1 - If yes for hospitalization or change in psychiatric medicine, please explain:* |
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Ap 1 - Do you currently, or have you previously, had any addiction? I understand that the regular use of substances, even if not an addiction, or if legal in my state, could result in the denial of our application by the country’s Central Authority.* |
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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. Also, please note that you will be required to submit legal documentation related to the removal of the child(ren) with your application.* |
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Ap 1 - Have you ever been under investigation by child protective services (regardless of whether or not the investigation was founded)?* |
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Ap 1 - If Yes, please explain in detail.* |
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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. |
Ap 1 Religion (required for Philippines Program)* |
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Ap 1 Active Church Member (required for Philippines Program)* |
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Ap 1's Amount of Religious Involvement* |
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Ap 2 Religion (required for Philippines Program)* |
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Ap 2 Active Church Member (required for Philippines Program)* |
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Ap 2's Amount of Religious Involvement* |
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If Applicants have different religions, what religion would child be reared?* |
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Prospective Adoptive Parent 2 |
Ap 2 First Name |
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Ap 2 Legal Middle Name |
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Ap 2 Last Name* |
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Ap 2 Name Prefix* |
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Nick Name |
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Gender Assigned at Birth* |
* |
Race* |
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Ap 2 Date of Birth* |
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Ap 2 Birthplace (City, State, Country)* |
* |
Birth Country* |
* | Show All Countries |
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PLEASE NOTE: If you were born outside of the US, you will be required to obtain a newly issued certified birth certificate from that country as part of your adoption process. |
Ap 2 Citizenship* |
* | Show All Countries |
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Ap 2 Cell Phone* |
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Ap 2 Email* |
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Ap 2 Preferred Contact Method* |
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Ap 2 Passport Number |
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Ap 2 - List States Previously Lived in since 18 years old (this includes other countries or states resided in for college/schooling)* |
* |
Ap 2 Dual Citizenship* |
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Countries where have Dual Citizenship for Ap 2* |
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Ap 2 - For any previous/current health conditions (including but not limited to: cancer, transplant, syndrome, heart disease, etc), please provide details explaining diagnosis, prognosis, treatment, life expectancy, and effect on daily life.* |
* |
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 - Have you been hospitalized due to a psychological condition or change in psychiatric medicine?* |
* |
Ap 2 - If yes for hospitalization or change in psychiatric medicine, please explain:* |
* |
Ap 2 - Do you currently, or have you previously, had any addiction? I understand that the regular use of substances, even if not an addiction, or if legal in my state, could result in the denial of our application by the country’s Central Authority.* |
* |
Ap 2 - If you answered yes for addiction(s), please explain:* |
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Ap 2 - Have any children in your care ever been removed, voluntarily or involuntarily, from your home?* |
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Ap 2 - If any children in your care have ever been removed from your home, please explain. Also, please note that you will be required to submit legal documentation related to the removal of the child(ren) with your application.* |
* |
Ap 2 - Have you ever been under investigation by child protective services (regardless of whether or not the investigation was founded)?* |
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Ap 2 - If Yes, please explain in detail.* |
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