Adoption Network of Colorado

Adoption Network of Colorado
7500 E. Arapahoe Rd., #250
Centennial, CO 80112
Phone: 303-691-0808
FOR AGENCY USE ONLY
Application Received Date: _________ Check Enclosed: Yes / No
Approved for formal app: Yes ____No ___ File number: _____________
Social Worker assigned to case:_________________ Rev 12/04

The information submitted in this application will be held strictly confidential within the limits of state law.

Preliminary Application Form
Applicant:
Work phone:
Age:
Spouse:
Work phone:
Age:
Address:
Street: City: State: Zip:
Home Phone:
FAX:
Home Email:
Applicant Work Email:
Spouse Work Email:
Date&place of marriage: Date of application:
Please give year of previous marriages and divorces, if any:
Applicant:
Spouse:
Children:
Age of birth children
 Age of adopted children:
Citizenship:
Applicant:
Spouse:
  
Why do you wish to adopt?
I am/we are interested in adopting the following child(ren):

Siblings?
Male  Female  Either Age range  How many siblings? Yes  No
I am/we are interested in adopting a child from:
United States
Other country
I/we are using an out of state placement agency, (name and phone)
Are you willing to adopt a child who has an incomplete social or medical history? Yes  No
Are you willing to adopt a child you have never met, or have only met briefly? Yes  No
Will both parents be able to travel to another country to complete the adoption? Yes  No
Are you willing to attend training and support group meetings before and after placement? Yes  No
Are you strongly motivated and willing to work hard toward completing an adoption? Yes  No
Are you willing to adopt a child that is not a newborn baby? Yes  No
Are you willing to accept a child with medical conditions that can be cured? Yes  No
Are you willing to accept a child who has temporary physical and developmental delays? Yes  No
Have you carefully considered your financial resources and planned for adoption expenses? Yes  No
Have you carefully considered your ability to give time and emotional energy to adoption? Yes  No
Are you particularly eager to parent a child with a specific problem, condition or situation? Yes  No
If yes, please explain:
How did you learn about Adoption Network of Colorado
?
Friend or Referral  Internet  Yellow Pages
Other: 
It is imperative that you disclose all requested information in an accurate manner, as the FBI fingerprint and criminal clearance process required by law will disclose all police charges and convictions. Charges or convictions do not necessarily preclude you from an approved homestudy. All cases are reviewed on a case-by-case basis. All information contained in this application will be held strictly confidential within the limits of state law.
Have either of you been charged with, or convicted of a crime? Yes  No
If yes, charge and date:
Have either of you had problems with substance abuse, i.e., alcohol, prescription drugs or other? Yes  No
Do either of you have medical conditions that may effect your ability to parent a child? Yes  No
Have either of you ever been involved in, accused of, or convicted of child abuse or neglect? Yes  No
Have either of you ever been involved in, accused of, or convicted of domestic violence? Yes  No
Have you ever had a homestudy completed by another agency or social worker? Yes  No
If yes, please list whether you were approved or not, and the agency name and phone number:
For any of the above that you answered as "yes", please attach a letter of explanation with the signature of both the applicant and the spouse.
Applicant's Employer
Job title Annual Salary  
Spouse's Employer
Job title Annual Salary  
References: Please list 3 references not related to you (their name, address and phone number and, if available, their email).
1.
2.
3.

STATEMENT OF UNDERSTANDING

I/We understand that we are submitting this Preliminary Application for the agency to assess whether Adoption Network of Colorado
 can offer us adoptive services. I/we state that the information we have given is true and complete. I/we understand the Preliminary Application fee is non-refundable, and does not guarantee an offer of adoption services through Adoption Network of Colorado
 nor does it guarantee the placement of a child.

I/We have thoroughly read and understand the information regarding the adoption services provided by Adoption Network of Colorado
 and wish to obtain a formal application with the intent of applying for adoption services if this Preliminary Application is approved.

I/We hereby give our permission for Adoption Network of Colorado
 and our previous and/or current adoption agency(s) to share information about us concerning our application(s) and assessments as adoptive parents.

Applicant's Signature
Date
Applicant's Signature
Date
Or print and return this application form to:     

Adoption Network of Colorado
7500 E. Arapahoe Road, Suite #250 Centennial, CO 80112
Or contact our office over the phone at 303-691-0808 for credit card payment