MotherFather
*Last Name
*First Name
Middle Name
Country
Address
City
State
Zip Code
*Home Phone
Fax Number
*E-mail 1
E-mail 2
E-mail 3
Work Phone
Cell Phone
Birth Date
Birth Place
Education
Occupation
Employer
Approximate Income
Family Savings
Height
Weight
Physical Health Issues (give details & dates in the Notes field)No

Yes
No

Yes
Mental Health Treatment (give details & dates in the Notes field)No

Yes
No

Yes
Substance Abuse History (give details & dates in the Notes field)No

Yes
No

Yes
Criminal Record History (give details & dates in the Notes field)No

Yes
No

Yes
Date of Marriage
Previous Marriages
How Many Kids Living at Home
Citizenship
3 Personal References and their Contact Information
Request for:
Homestudy
Foreign Placement
Hosting Program
Non-Placement Services
Country and/or Ethnicity of Child Desired
Initial Application for Child Placement Questionnaire
Please describe why you want to host and/or adopt and if there is a reason you prefer to adopt from a certain country/region
Please describe the child or children you wish to host and/or adopt. Include age range, race, health or handicap, number of siblings, and whether or not you would accept either sex:
Please share how you heard of About A Child (i.e. personal referral, newspaper ad, internet site, etc.)
Study Process; Documentation; Travel
Do you have an approved home study by a licensed child-placement agency?  

Completion Date (if not yet completed, anticipated completion date)  

If yes, give name of agency, social worker, address, telephone number and e-mail.


If no, please have your social worker contact About A Child for a home study outline. Explain your specific plan, if known, and time frame for receiving a home study, giving name of anticipated agency.
USCIS Status - Have you opened an I-600A file with your local U.S. CIS Citizenship and Immigration Service office?  

If yes, in what city?     Date filed

Have you received the I-600A approval notice?  

If yes, Date Approved
Do you at present have an active application with any other agency where there is a possibility of the placement of a child with you?    If yes, please explain.

Most countries require the parents to travel to adopt their child. This trip may last from three days to six weeks, depending upon the laws of the country. Please indicate any travel constraints:

Please include any other comments here.
I/We, the undersigned, hereby confirm under the penalties of perjury that all of the information contained herein is current, complete and accurate, upon our personal knowledge.

I/We, the undersigned, hereby confirm under the penalties of perjury that I/We have read and accepted AAC Policies and Procedures and promise to adhere to them at all times when utilizing AAC services or accessing AAC web site restricted areas.

Mother InitialsFather Initials
Date
Please e-mail your family photos to adopt@aboutachild.org or send them to

About A Child
479 Tiller Ln.
Redwood City, CA 94065

for scanning and upload.