CATHOLIC CHARITIES ADOPTION SERVICES PRE-APPLICATION

MALE Name: DOB: Age: Occupation: Cell#: Email:             FEMALE Name: DOB: Age: Occupation: Cell#: Email:             GENERAL Address: Home Phone# City: Household Income: State: Marital Status: Married Divorced Single (never married) Widowed Zip:

1. If married, were you married in the Catholic Church?       Yes No   Date of marriage:   Place of marriage:     2. Do you have any children?      Yes No   Please list their names & ages:

3. Are you a member of any church?      Yes No   Name of Church: Name of Pastor:

4. Are you enrolled in an Indian Tribe? Male: Yes No Female: Yes No   Name of tribe:   If yes, send a copy of your CDIB card

5. Have you ever been arrested, charged or convicted of a felony or misdemeanor? Yes No   Please describe:

6. Are you a U.S. Citizen? Male: Yes No Female: Yes No   Please explain:

7. Are you interested in adopting:   African American Child: Yes No Asian Child: Yes No Bi-racial Child: Yes No Caucasian Child: Yes No Hispanic Child: Yes No Native American Child: Yes No Older Child (>1yr old) Yes No Child with minor medical needs: (cleft palate, cleft lip, surgically correctable complications) Yes No Child with major medical needs? (HIV, hepatitis C, seizures) Yes No Child with sibling group? Yes No

8. If you are interested in Domestic Adoption, are you willing...   ... to meet the birth parents? Yes No ... to exchange pictures with the birth parents? Yes No ... to have contact with the birth parents after placement? Yes No

9. Are you interested in International Adoption?       Yes No   What country?       China Colombia Ethiopia Kazakhstan Russia Vietnam Undecided

10. Would you like to attend an orientation seminar regarding:   -- Domestic adoption? Yes No -- International adoption? Yes No

11. Would you like us to place your name(s) on the mailing list for the educational/study group for adoptive parents? To adopt, ten hours of training is required.   Yes No

12. Have you been a resident of the state of Oklahoma for the past five consecutive years?   Yes No

13. Have you participated in an Adoption Home Study in the past?       Yes No   Did you receive a favorable recommendation? Yes No Date of Adoption Home Study: Send us a copy of your Adoption Home Study with your Pre-Application

Comments:

Digital Signature: Enter your initials

Male: Female: