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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