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Adopting God’s Children, Inc.
AGC 10720 Santa Laguna Drive AGC Boca Raton, FL 33428 AGC Phone: 845-558-0786
Family Information and Registration Form
Please note: This application is an opportunity for you to share information about your family. There is a non-
refundable application fee of $350.00 which is due with the submission of this application and covers the
processing of the application and the preparation for the referral.
Please print in black or blue ink.
Contact Information:
FAMILY NAME:________________________________________________APPLICATION DATE:__________________________
Address:_________________________________________________________________________________________________
City:___________________________________________ State:___________________________ Zip:_____________________
Phone Number:__________________________ Fax:_____________________ E-Mail: __________________________________
Prospective Adoptive Father:
NAME: (First, Middle, Last) ______________________________________________Cell Number: __________________________
Date of Birth: _______________________ Age: _________ Place of Birth: ____________________________________________
Divorced: Yes__ No__ Religion: _______________________ Race: __________________________
Citizenship: ______________________ Education: (Highest Level) ___________________________________________________
Employer: ____________________________________________________Title: ________________________________________
Employer Phone Number: ______________________Date of Employment: __________________ Annual Income: ____________
Social Security Number: __________________________________________________
Date of Present Marriage: _____________ City/State: ____________________________________________________________
Number of previous marriages: please include spouses, dates of marriage, reason for termination
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
___
Passport Number: _____________________________Passport Issuing Office: _________________________________________
Driver’s License #:____________________________________ State issued: _________________ Expiration Date: ____________
Prospective Adoptive Mother:
NAME (First, Middle, Last): __________________________________________________ Cell Number: _____________________
Date of Birth: _________________________ Age: __________ Place of Birth: ________________________________________
Divorced: Yes__ No__ Religion: _______________________ Race: ______________________________
Citizenship: __________________________ Education: (Highest Level) _______________________________________________
Employer: ____________________________________________________ Title: _______________________________________
-1-
Employer Phone Number: _________________________ Date of Employment: _______________ Annual Income: ____________
Social Security Number: ______________________________________
Date of Present Marriage: ________________________ City/State: ____________________________________________
Number of previous marriages: please include spouses, dates of marriage, reason for termination
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
___
Passport Number ________________________________Passport Issuing Office________________________________________
Driver’s License #: ___________________________________ State Issued: ___________________ Expiration Date: __________
Family Information:
Please list all other people residing in your home, including children, relatives, roommates and boarders.
Name Date of Birth Relationship School Grade/Occupation
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
______
Other children not residing in the home:
Name Date of Birth Relationship Gender Adopted/Location School Grade/Occupation
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
_____
General Health:
If you answer yes to any of the questions in General Health or Legal, please attach a letter of explanation to the registration form.
Husband Wife
Have either of you been diagnosed with a significant illness? _________ _________
Have either of you had major surgeries? _________ _________
Have either of you been treated by a Mental Health Professional? _________ _________
Have either of you been treated for substance abuse/alcoholism? _________ _________
Are either of you on any current medications? _________ _________
If so, for what condition? __________________ __________________
Have either of you been on any medication for depression
Or any other psychiatric diagnosis? _________ _________
If so, what was/is the medication? __________________ __________________
Specifically, what is it prescribed for? __________________ __________________
Legal History:
Husband Wife
Have you ever been arrested? _________ _________
If yes, list dates and arrest: __________________ __________________
Have you been convicted of a felony? _________ _________
If yes, list dates and convictions: __________________ ____________________
-2-
Have you been convicted of a misdemeanor? _________ _________
If yes, list dates and convictions: __________________ ____________________
Have you ever applied for adoption? _________ _________
If yes, with whom and why are you seeking another
adoption agency?
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Home Study:
Do you have a completed home study? Yes: _____ No: _____ If yes, date completed and by whom? (Please include address and phone
number of agency and/or social worker)
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Any previously rejected home study? Yes: _____ No: _____ If yes, please explain and by whom (Please include address and phone number of
agency and/or social worker)
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Child to be Adopted:
Please provide the following characteristics of a child you wish to adopt. (Home Study applicants, please do not fill in this section)
Age Range: Minimum to Maximum: __________________ Gender: Male: _____ Female: _____ Either: _____ Siblings: _____
Would you accept a known minor correctable handicap? ( cleft palate, birth mark) ________
Would you accept a permanent handicap? (blindness, deafness...) _________
Domestic Adoption:
Caucasian: ____________
Hispanic: ____________
African American: ____________
Asian: ____________
Native American: ____________
Bi-Racial: ____________
Country of Choice: US: _____ Other: _______________
In case of an emergency:
Please list the name, address and phone number of a person we can contact.
Name___________________________________________
Address_________________________________________
City____________________________ State___________________________ Zip________________________
Phone Number ___________________________________ Cell Number ________________________________
-3-
I/We understand that Adopting God’s Children, Inc. cannot guarantee placement of a child or a time by
which a child will be placed. I/We have reviewed this family information and all the information is true and
correct.
________________________________________________ ______________
Prospective Adoptive Father’s Signature Date
________________________________________________ ______________
Prospective Adoptive Mother’s Signature Date
Sworn to or affirmed before me this _____ day of _____ 201_ by ___________________________
and ______________________________.
Personally Known: __________________
Provided Identification: ______________
Type of Identification Provided: __________________
Notary’s Signature: ___________________________
My Commission Expires: ______________________
-4-
-4-

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AGC - Application

  • 1. Adopting God’s Children, Inc. AGC 10720 Santa Laguna Drive AGC Boca Raton, FL 33428 AGC Phone: 845-558-0786 Family Information and Registration Form Please note: This application is an opportunity for you to share information about your family. There is a non- refundable application fee of $350.00 which is due with the submission of this application and covers the processing of the application and the preparation for the referral. Please print in black or blue ink. Contact Information: FAMILY NAME:________________________________________________APPLICATION DATE:__________________________ Address:_________________________________________________________________________________________________ City:___________________________________________ State:___________________________ Zip:_____________________ Phone Number:__________________________ Fax:_____________________ E-Mail: __________________________________ Prospective Adoptive Father: NAME: (First, Middle, Last) ______________________________________________Cell Number: __________________________ Date of Birth: _______________________ Age: _________ Place of Birth: ____________________________________________ Divorced: Yes__ No__ Religion: _______________________ Race: __________________________ Citizenship: ______________________ Education: (Highest Level) ___________________________________________________ Employer: ____________________________________________________Title: ________________________________________ Employer Phone Number: ______________________Date of Employment: __________________ Annual Income: ____________ Social Security Number: __________________________________________________ Date of Present Marriage: _____________ City/State: ____________________________________________________________ Number of previous marriages: please include spouses, dates of marriage, reason for termination ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ___ Passport Number: _____________________________Passport Issuing Office: _________________________________________ Driver’s License #:____________________________________ State issued: _________________ Expiration Date: ____________ Prospective Adoptive Mother: NAME (First, Middle, Last): __________________________________________________ Cell Number: _____________________ Date of Birth: _________________________ Age: __________ Place of Birth: ________________________________________ Divorced: Yes__ No__ Religion: _______________________ Race: ______________________________ Citizenship: __________________________ Education: (Highest Level) _______________________________________________ Employer: ____________________________________________________ Title: _______________________________________ -1- Employer Phone Number: _________________________ Date of Employment: _______________ Annual Income: ____________
  • 2. Social Security Number: ______________________________________ Date of Present Marriage: ________________________ City/State: ____________________________________________ Number of previous marriages: please include spouses, dates of marriage, reason for termination ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ___ Passport Number ________________________________Passport Issuing Office________________________________________ Driver’s License #: ___________________________________ State Issued: ___________________ Expiration Date: __________ Family Information: Please list all other people residing in your home, including children, relatives, roommates and boarders. Name Date of Birth Relationship School Grade/Occupation ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ______ Other children not residing in the home: Name Date of Birth Relationship Gender Adopted/Location School Grade/Occupation ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ _____ General Health: If you answer yes to any of the questions in General Health or Legal, please attach a letter of explanation to the registration form. Husband Wife Have either of you been diagnosed with a significant illness? _________ _________ Have either of you had major surgeries? _________ _________ Have either of you been treated by a Mental Health Professional? _________ _________ Have either of you been treated for substance abuse/alcoholism? _________ _________ Are either of you on any current medications? _________ _________ If so, for what condition? __________________ __________________ Have either of you been on any medication for depression Or any other psychiatric diagnosis? _________ _________ If so, what was/is the medication? __________________ __________________ Specifically, what is it prescribed for? __________________ __________________ Legal History: Husband Wife Have you ever been arrested? _________ _________ If yes, list dates and arrest: __________________ __________________ Have you been convicted of a felony? _________ _________ If yes, list dates and convictions: __________________ ____________________
  • 3. -2- Have you been convicted of a misdemeanor? _________ _________ If yes, list dates and convictions: __________________ ____________________ Have you ever applied for adoption? _________ _________ If yes, with whom and why are you seeking another adoption agency? _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Home Study: Do you have a completed home study? Yes: _____ No: _____ If yes, date completed and by whom? (Please include address and phone number of agency and/or social worker) _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Any previously rejected home study? Yes: _____ No: _____ If yes, please explain and by whom (Please include address and phone number of agency and/or social worker) _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ _________________________________________________________________________________________________________ Child to be Adopted: Please provide the following characteristics of a child you wish to adopt. (Home Study applicants, please do not fill in this section) Age Range: Minimum to Maximum: __________________ Gender: Male: _____ Female: _____ Either: _____ Siblings: _____ Would you accept a known minor correctable handicap? ( cleft palate, birth mark) ________ Would you accept a permanent handicap? (blindness, deafness...) _________ Domestic Adoption: Caucasian: ____________ Hispanic: ____________ African American: ____________ Asian: ____________ Native American: ____________ Bi-Racial: ____________ Country of Choice: US: _____ Other: _______________ In case of an emergency: Please list the name, address and phone number of a person we can contact. Name___________________________________________ Address_________________________________________ City____________________________ State___________________________ Zip________________________
  • 4. Phone Number ___________________________________ Cell Number ________________________________ -3- I/We understand that Adopting God’s Children, Inc. cannot guarantee placement of a child or a time by which a child will be placed. I/We have reviewed this family information and all the information is true and correct. ________________________________________________ ______________ Prospective Adoptive Father’s Signature Date ________________________________________________ ______________ Prospective Adoptive Mother’s Signature Date Sworn to or affirmed before me this _____ day of _____ 201_ by ___________________________ and ______________________________. Personally Known: __________________ Provided Identification: ______________ Type of Identification Provided: __________________ Notary’s Signature: ___________________________ My Commission Expires: ______________________
  • 5. -4-
  • 6. -4-