ASAP Pre-Application


Please complete all applicable fields.

Personal Information
Parent 1
First Name
Last Name
Occupation
Date of Birth (e.g. 01-08-2001)
Home Phone
Cell Phone
Work Phone
E-Mail Address
Parent 2
First Name
Last Name
Occupation
Date of Birth (e.g. 01-08-2001)
Home Phone
Cell Phone
Work Phone
E-Mail Address
Address 1:
Address 2:
City:
State:
Zip Code:
Marital Status
Date of Marriage
(e.g. 01-08-2001)
Children at Home
Child 1
Full Name
Date of Birth:
(e.g. 01-08-2001)
Adopted: Biological:
Race:
Child 3
Full Name
Date of Birth:
(e.g. 01-08-2001)
Adopted: Biological:
Race:
Child 2
Full Name
Date of Birth:
(e.g. 01-08-2001)
Adopted: Biological:
Race:
Child 4
Full Name
Date of Birth:
(e.g. 01-08-2001)
Adopted: Biological:
Race:
Please tell us about your other children in the space titled More About Your Family.
Home Study Agency
Name of Agency
Current Caseworker
Telephone
Ext
Please tell us about the child you would like to adopt:
Sex 
 
Race
Black   White   Hispanic   Asian
Biracial   No preference
 
Age Range
Newborn under 6 months   Baby/Toddler (6-24 months)   Preschool (24-48 months)
 
Special Issues
 Moderate non-correctable medical problems, such as some congenital anomalies and some syndromes.
 
 Severe medical problems, such as: medically fragile, more severe cerebral palsy, shortened life span and multiple handicaps.
 
 Extreme prematurity (26 weeks and under). Birth weight under 2 lbs. 8 oz.
(Significantly increased risk for physical and neurological issues.)
 
 Likely moderate cognitive disabilities—not Down syndrome
 
 Down syndrome
 
 Down syndrome with cardiac or other significant medical involvement
 
 Brain anomolies- outcome uncertain
 
 Anticipated severe to profound cognitive disabilities
 
 Potential for alcohol-related disabilities due to significant prenatal exposure to alcohol
 
 Significant heavy use of drugs by birth mother—Child at risk for behavior, attention, learning and other challenges. (In these circumstances, alcohol use cannot be ruled out.)
 
 Infant currently exhibiting atypical neurological development (e.g. hypertonicity, tremors, fisting) etiology is unknown. May significantly increase risk for neurological and behavorial issues as the child matures.
 
 Child at risk for mental illness—one birth parent mentally ill
 
 Child at risk for mental illness—both birth parents mentally ill
 
 Other issues (Please note in comments section)
 
Legal Risk Placement 
 
Could your family be a resource for an infant if Medicaid and subsidy payments are not available? 
Comments
Other specific physical issues with which you are comfortable:
Other specific mental/cognitive issues with which you are comfortable:
Additional Comments
Experience
What, if any, experience do you have caring for children with special needs?
More About Your Family
Is there anything else you wish to tell us about yourself and/or your family?
Choosing Spence-Chapin
How did you hear about Spence-Chapin? (please be specific)

Newspaper:


TV/Radio:


Internet:


Other/Network Agency:


Conference/ Workshop
Magazine
Yellow Pages
Adoptive Parent
Reputation/Friend
Other Source

If Other: