IAN Application Form

International Adoption Net
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.

IAN Preliminary Application Form
Date of Application:    
Have you already contacted IAN for program information? Yes  No
Applicant Name: Age:  
Spouse Name: Age:  
Preferred Email:    
Secondary Email:    
Preferred Phone #:    
Secondary Phone #:    
Address:  Street: 
                City:          State:  Zip: 
Date & place of marriage:  
Please give year of previous marriages and divorces, if any:
     Applicant:   Spouse:  
Children:
     Please list the number of children in your family:
     Birth children:                       Adopted children:  
     Please give the ages of your: (separated by comma)
     Birth children:                  Adopted children:  
Citizenship:    
     Applicant:  Spouse:  
     
Why do you wish to adopt?
     
I am/we are interested in adopting the following child(ren): 
     Age Range:     Male  Female  Either
     Are you open to adopting multiple children?      Yes  No
I am/we are interested in adopting a child from:
     USA (State):       Other country: 
PLEASE ANSWER ALL THE FOLLOWING QUESTIONS:
I/we are using an out of state placement agency, (name and phone if applicable):  
     
Are you willing to adopt a child who has an limited social or medical history (i.e. child is abandoned, birth parent unknown or deceased)? 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 (i.e. malnutrition, anemia, premature birth, etc)? 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 planning to move or renovate your house in the next 18 months? Yes  No
Are you particularly eager to parent a child with a specific problem, condition or situation? Yes  No
    If yes, please explain: 
   
Have the applicant(s) lived in another state or country since the age of 18? Yes  No
    If yes, please list which states/countries and which applicant lived there:  
     
Is anyone other than yourselves, currently living in your home that is 18 years or older? Yes  No
    If yes, please list the name and relationship to yourself:
   
How did you learn about International Adoption Net?
    Friend or Referral  Internet  Rainbow Kids
    Please provide the name of the friend, internet site or 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
Have you ever had an unfavorable homestudy? 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 email a letter of explanation with the signature of both the applicant and the spouse to:  info@internationaladoptionnet.org
 
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 International Adoption Net 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 International Adoption Net nor does it guarantee the placement of a child.

I/We have thoroughly read and understand the information regarding the adoption services provided by International Adoption Net 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 International Adoption Net 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
Spouse Signature
Date
There is a $250 application fee which must be received before we can process your application.
 
If you are submitting the application online, please call the office at 303-691-0808 to arrange payment by credit card or to request a Paypal invoice.  To send your application online, please click on the SUBMIT button below. 

You may also print this application page and mail it with payment to:      

International Adoption Net,
7500 E. Arapahoe Road, Suite #250
Centennial, CO 80112