PRELIMINARY SCREENING FORM*
[pic]
Preliminary Application
Date: ______________________
Full Name: DOB:
Status: ___Married ___Widowed ___Divorced ___Single (Date of Marriage):______________
Spouse’s Full Name: DOB:
Address:
City: County: State: Zip:
Home Telephone: Fax: ____________________
Your Home: (Apartment, Condo or House) ___________How long?_________ ( )Rent ( )Own
Prospective Adoptive Parent’s Information
Employer ________________________ Position: ________________Work Phone__________
Annual Salary _____________________Work Address:
Cell Phone: Email Address: _____________________________
Religion _____________________Race___________________ Education__________________
Height: Weight: Nationality:
Previous Marriage(s):___________________Date: Dissolution:
Prospective Adoptive Parent’s Information
Employer ________________________ Position: ________________Work Phone__________
Annual Salary _____________________Work Address:
Cell Phone: Email Address: _____________________________
Religion _____________________Race___________________ Education__________________
Height: Weight: Nationality:
Previous Marriage(s):___________________Date: Dissolution:
Children:
Name Birth Date By Birth or Adoption Resides With Nationality/Race
Please complete the following questions. Use additional paper if needed.
1. How did you hear about Florida Adoption Center LLC ________________________________________________________________________
2. Do you have a completed home study? ________When:______ By:_________________
3. Why have you chosen to pursue adoption as a means of growing your family?
________________________________________________________________________
________________________________________________________________________
_______________________________________________________________________
4. Have you previously or are you undergoing fertility testing? List any alternate methods of conception (i.e. in vitro fertilization or artificial insemination)? Please explain. Provide name of Physician(s) and dates when medical treatment was discontinued____________
________________________________________________________________________
5. Please discuss any medical problems or chronic illness of either spouse. Provide name of physician(s). Please include past or current treatment for psychiatric or chemical dependency problems______________________________________________________
________________________________________________________________________
6. Please describe the type of child you feel would fit into your family at this time. Include age range, race(s) and health. Adoption Preference: No Preference ____Undecided____
Race: Caucasian____ Hispanic____ African-American ____Bi-Racial ___Other:______
Age: Newborn ___Older child (Age Preference_____) Gender: Male ____Female____
Special Needs: Y N Health Issues: Y N Drug Exposed: Y N
Willing to accept: Marijuana___ Cocaine___ Methadone___ Alcohol____ Tobacco____ Opiates___ Methamphetamines___ Barbiturates___ Psychotropic___ Benzodiazepine___
________________________________________________________________________
________________________________________________________________________
We, the adoptive family, willingly submit the $250.00 fee with this application. We acknowledge that this preliminary application fee is non-refundable. Please make your check payable to Florida Adoption Center LLC. and mail to: 1600 Sarno Road, Bldg. A. Suite 8, Melbourne FL 32935.
Signature _______________________________________________ Date: _________________
Signature _______________________________________________ Date: _________________
**Please email a recent photograph of your family to Andrea@ when you submit this Preliminary Application and Preliminary Application fee. **
If this form is not returned within 30 days from the original mailing or receipt, we will assume you are no longer interested.
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- c amendment petition form florida
- change replacement or surrender request
- department of health office of medical
- change replacement or surrender request instructions
- application for medical marijuana treatment center
- medical marijuana consent form florida board of medicine
- welcome to rural development rural development
- medical marijuana general liability application
- wwwwwwwwwwwwwwwww
- st petersburg college
Related searches
- how to calculate preliminary net income
- army preliminary marksmanship instruction
- preliminary change of ownership statement
- california preliminary change ownership form
- los angeles county preliminary change
- preliminary change of ownership
- preliminary change of ownership pdf
- preliminary change of ownership san diego ca
- preliminary change in ownership form
- preliminary change of ownership california
- vanguard preliminary capital gains estimates
- oregon preliminary teaching license