SC COAC Adoption Interest Form

Your Name Age Race (for demographic purposes only):

Marital Status: Married Single Separated Divorced Widow Select One If Married, Number of Years:

Spouse Name: Spouse Age: Spouse Race (for demographic purposes only):

Your Street/Post Office Address:

Your City: State/Province: Zip: Country:

Your Home Phone Number: Work Phone: Ext: Fax Number: E-Mail Address:

If you have children at home, how many and what ages?
Number of children at home:
Boys at home Ages: Girls at home Ages:

I/We are interested in adopting:
Single Child
Siblings *
Either

* If interested in Siblings or more than one child, how many children will you accept?

Gender Preferred: Any Female Male Siblings-Boys Siblings-Girls Siblings-Both Siblings-Any Select One

Age Range I/we will accept (check all that apply):
Any Age .. 1-3 Yrs .. 4-6 Yrs .. 7-9 Yrs .. 10-12 Yrs .. 13-15 Yrs .. 16-18 Yrs

I/We will accept children with the following special conditions (check all that apply):
Physical Disabilities .. Emotional Disabilities .. Mental Disabilities .. Learning Disabilities

Would you consider a child that has been sexually abused? Yes .. No

I/We have a current home study with a state agency: Yes .. No If yes, what state and agency?

Are you interested in International Adoption? Yes .. No

Comments or Questions I/we have (You may include any parenting experience, experience with children, family strengths, interests, adoption training, additional information you would like included on this Web site, or anything else you want us to know or you want to ask.):

I/We wish to be contacted by: Phone .. E-Mail .. Phone or E-Mail .. Regular Postal Mail