Registration Date:
_____________
Enter second applicant information, only if applicable for
your family.
|
First Applicant Title: _____ Last Name: ______________ MI:
_____ First Name: ________________ Birth Date: ______________ Sex: ______ (mm/dd/yyyy) Ethnicity: (Check up to 3) []
African American [] Asian []
Caucasian []
Hispanic/Latino []
Native American [] Pacific
Islander Religion:
___________________________ Primary Language: ___________________ Secondary
Language: ________________ Income
Source: _____________________ Occupation:
________________________ Work
Phone: ______________ Ext. _____ Marital
Status: ________ Date
of Marriage if applicable (mm/dd/yyyy): ____________ |
Second Applicant Title: _____ Last Name: ______________ MI:
_____ First Name: ________________ Birth Date: ______________ Sex: ______ (mm/dd/yyyy) Ethnicity: (Check up to 3) []
African American [] Asian []
Caucasian []
Hispanic/Latino []
Native American [] Pacific
Islander Religion:
___________________________ Primary
Language: ___________________ Secondary
Language: ________________ Income
Source: _____________________ Occupation:
________________________ Work
Phone: ______________ Ext. _____ |
Address: _______________________________________________________________
City:
County: __________________________ Home Telephone: ______________________
Email Address: ____________________________________
International Address: ________________________________
Number of children raised: _______
Number of children in the home: _______
Please
Provide Information About the Child(ren) Your Family Can Accept:
Gender: [] Male [] Female
Family
Composition:
[] Single
[] Sibling Group
Youngest Age
Acceptable: __________ Oldest Age Acceptable:
__________
Minimum
Number of Children Acceptable: _________
Maximum
Number of Children Acceptable: _________
- Physical Disability –
Select the highest level that is acceptable:
[] Does not Matter []
None [] Mild [] Moderate [] Severe
- Emotional Disability –
Select the highest level that is acceptable:
[] Does not Matter []
None [] Mild [] Moderate [] Severe
- Mental Disability – Select
the highest level that is acceptable:
[] Does not Matter []
None [] Mild [] Moderate [] Severe
- Learning Disability –
Select the highest level that is acceptable:
[] Does not Matter []
None [] Mild [] Moderate [] Severe
- Overall Level of Functioning
– Select the highest level that is acceptable:
[] Does not Matter []
0 [] 1 []
2 [] 3
Check all
specific disabilities your family might be interested in accepting:
|
DOES NOT MATTER
Adjustment disorder
Amputee
Anorexia
Asthma
Autism
Blindness, correctable
Cancer
Cleft lip
Craniofacial anomalies
Deaf/Profound hearing loss
Development articulation disorder
Down Syndrome
Dyscalculia
Dystonia
Enuresis
Failure to thrive
Fragile X syndrome
HIV positive
Heartmurmur
Ichtyosis
Kidney disease
Mental Retardation - cause not specified
Microcephalus
Muscular Dystrophy
Non Specific Learning Disability
Osteogenesis imperfecta
Perceptual Impairment
Physical Disability
Prader Willi syndrome
Psychosis
Receptive language disability
Rheumatoid Arthritis
Schizophrenia
Separation anxiety disorder
Sickle cell trait
Takes psychiatric medication
Trisomy 13
Wheel Chair Dependent |
NONE
Albinism
Anemia/blood disorder
Aphasia
Attachment Disorder
Behavior Problems
Blindness, will never have sight
Central auditory processing disorder
Cleft palate
Crohn’s disease
Depression
Developmental writing disorder
Drug Exposed
Dyslexia
Emotional Problems
Epilepsy
Fetal Alcohol Effect
Generalized anxiety disorder
Hearing Loss partial
Hydrocephalus
Immune system disorder
Lead poisoning
Mental Retardation – genetic
Motility disorders
Neurofibromatosis
Obsessive compulsive disorder
Paralysis – partial paraplegic
Pervasive developmental disorder
Pica
Progeria
Respiratory problems
STD
Scoliosis
Shaken baby syndrome
Speech disorder
Terminal Illness
Trisomy 18
Williams syndrome |
AIDS
Allergies
Angelman syndrome
Asperger’s syndrome
Attention Deficit Disorder
Bipolar disorder
Borderline personality disorder
Cerebral palsy
Conduct disorder
Cystic Fibrosis
Developmental Disabilities
Diabetes
Dwarfism
Dysthymia
Encopresis
Expressive language disorder
Fetal Alcohol Syndrome
Growth disorders
Heart defect
Hyperactivity
Irritable bowel syndrome
Loss issues
Metabolic disorder
Motor skills disorder
Neurological impairment
Oppositional defiant disorder
Paralysis – quadriplegic
Phenylketonivia (PKU)
Post traumatic stress disorder
Prune belly syndrome
Reactive-attachment disorder
Rett’s disorder
Schizo-affective
disorder
Seizure disorder
Sickle cell anemia
Spina bifida
Tourette syndrome
Visually impaired |
|
Check all specific risk factors your family might be
interested in accepting: |
||
|
DOES NOT MATTER
Drug Exposed
History of multiple placements
Mental Retardation in the Birth family |
NONE
HIV exposed
Lead poisoning
Premature birth |
Alcohol exposed
History of abuse or neglect
Mental Illness in birth family
Schizophrenia in birth family |
List
specific conditions and risk factors that your family cannot accept:
Please enter a narrative for your family. Narratives should be between 240 and 400
words in length.
Confidential Information: In this field, please give any other information that would only be pertinent to social workers.