Family Website Registration MATCH Form



(Check One) Initial Website Referral Profile Update Today’s Date:      

Photo attached Digital Photo emailed, on (date):      

|Family Information |

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|Parent #1 (First & Last) Name:      Gender:       Date of Birth:      |

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|Parent #2 (First & Last) Name:      Gender:       Date of Birth:       |

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|Family Residence Address:       |

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|City      State       Zip      County:       |

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|Home Phone: (     )       Cell Phone: (     )       E-mail:       |

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|MAPP/NTDC enrolled date:       MAPP/NTDC completed date:       |

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|Home Study start date:       Home Study approved date:       Home Study update done:       |

|Race Parent #1 (check up to two): |Race Parent #2 (check up to two): |Marital Status: |

|Caucasian African American |Caucasian African American |Single Engaged Married |

|Hispanic Asian |Hispanic Asian |Divorced Domestic Partner |

|American Indian |American Indian |Primary Family Language: |

| | |English Spanish Other |

|Children in the home |

|Name |Age |Other Information |

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Child Characteristics Checklist

Instructions: Please use the list below to let us know the type of child(ren) you would like to adopt by placing an X in the appropriate box.

|Gender/Sex |Number of Children/Siblings |Age of Child |

|Female |Single child with no siblings |5 and under |

|Male |Sibling group of 2 |6 |

|Transgender |Sibling group of 3 |7 |

|Non Binary |Sibling group of 4 |8 |

|All of the above |Sibling group of 5 or more |9 |

| |All of the above |10 |

|Race/Ethnicity (Check all that apply) | |11 |

|Caucasian | |12 |

|Hispanic | |13 |

|African American | |14 |

|Asian | |15 |

|American Indian | |16 |

|Biracial | |17 |

|Other | |18 |

|All of the above | |All of the above |

|Behaviors: |Behaviors Cont: |Behaviors Cont.: |

|Cruelty to animals |Hyperactive |Physically acts out towards adults |

|Damages property |Inappropriate Interactions with Strangers |Physically acts out towards peers |

|Displays oppositional behavior |Lack of awareness of others |Runs away |

|Fire setting |Lying |Sexually acts out with peers |

|History of playing with matches |Masturbates in public |Sexually provocative behavior |

|Unable to sustain attention | |Stealing |

| | |Other _____________________ |

|IEP for behavior | | |

| | |Overall level of Behaviors: |

| | |None Mild Moderate Severe |

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|Physical / Medical: |Physical / Medical Cont. |Physical / Medical Cont. |

|Amputee |Enuresis |Rheumatoid Arthritis |

|Anemia/Blood Disorder |Epilepsy |Scoliosis |

|Asthma |Fetal Alcohol Spectrum Disorder |Seizure Disorder |

|Attention Deficit Hyperactivity Disorder, |Fetal Alcohol Syndrome |Sickle Cell Anemia |

|Inattentive Presentation |Hearing Loss - Partial |Sickle Cell Trait |

|Attention Deficit Hyperactivity Disorder, Impulsive |Heart Defect |Speech Disorder |

|Presentation |Hydrocephalus |Spina Bifida |

|Blindness - Permanent |Irritable Bowel Syndrome |Terminal Illness |

|Cancer Paralysis - Quadriplegic |Kidney Disease |Tourette Syndrome |

|Cerebral Palsy Respiratory Problems |Life Threatening Viral Infection |Visually Impaired |

|Craniofacial Anomalies |Microcephaly |Wheel Chair Dependent |

|Cystic Fibrosis |Muscular Dystrophy |Other      _ |

|Deaf - Profound Hearing Loss |Neurofibromatosis |(please specify) |

|Dwarfism |Paralysis - Partial Paraplegic | |

|Encopresis | | |

| | |Overall level of Physical/Medical: |

| | |None Mild Moderate Severe |

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|Emotional: |Developmental Disabilities |Learning Needs |

|Adjustment Disorder |Asperger's Syndrome |Central Auditory Processing Disorder |

|Anorexia |Autism |Motor Skills Disorder |

|Attachment Disorder |Down Syndrome |Developmental Articulation Disorder |

|Bipolar Disorder |Drug/Alcohol Exposed |Non-Specific Learning Disorder |

|Conduct Disorder |Intellectual/Developmental Disability Not Specified |Dyslexia |

|Depression |Intellectual/Developmental Disability Genetic |Receptive Language Disability |

|Generalized Anxiety Disorder |Heart Defect |Expressive Language Disorder |

|Loss Issues |Pervasive Development Disorder |IEP (Learning Disability) |

|Obsessive Compulsive Disorder |Shaken Baby Syndrome |IEP (Gifted) |

|Oppositional Defiant Disorder |Other __     ___ |Other__     __ |

|Post Traumatic Stress Disorder |Overall level of Developmental Disabilities: |Overall level of Learning Needs: |

|Psychosis |None Mild Moderate Severe |None Mild Moderate Severe |

|Reactive Attachment Disorder | | |

|Schizophrenia | | |

|Schizophrenic Affective Disorder | | |

|Separation Anxiety Disorder | | |

|Takes Psychiatric Medication | | |

|Other__     __ | | |

|Overall level of Emotional: | | |

|None Mild Moderate Severe | | |

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|Risk Factors: |Risk Factors Cont.: |Risk Factors Cont.: |

|Alcohol Exposed in Utero |History of Multiple Placements |Criminal Activity |

|History of Abuse or Neglect |Intellectual/Developmental Disability in Birth Family |Schizophrenia in Birth Family |

|Mental Illness in Birth Family |Failure to Thrive |Sexual Abuse |

|Drug Exposed in Utero |Premature Birth |Other__     __ |

| | |None |

Family Narrative

Please describe yourself/family with something you would like people to know about you (i.e. hobbies, interests, and unique characteristics).

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Consent/Release for Kansas Adoption Exchange web site and AdoptUSKids national web site

I hereby agree and consent to the use of my photograph and/or image and usage of statements made by me featured on the AdoptKSKids and the AdoptUSKids website mediums for purposes of child matching, and I waive all claims for compensation or damages. (Approval statement indicates that a discussion has been held with the adoptive parent(s) about listing their information on the Exchange.)

Adoptive Parent’s Approval:       Date:      

Adoptive Parent’s Approval:       Date:      

Name of Assigned Worker:       Date:      

Name of Agency:      

Agency address:       City:       State:       Zip:     

(     )      (     )           

Agency Phone Agency Fax E-Mail

|Please email completed forms along with current photo to: customercare@ |

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