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 |
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The information submitted in this application will be held strictly
confidential within the limits of state law.
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IAN Preliminary Application Form |
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PLEASE ANSWER ALL THE FOLLOWING QUESTIONS: |
I/we are using an out of state placement agency, (name and phone if applicable): |
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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: |
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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:
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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:
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How did you learn about International Adoption Net? |
Friend or Referral Internet Rainbow Kids |
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Please provide the name of the friend, internet site or other: |
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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. |
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Have either of you been charged with, or convicted of a crime? |
Yes No |
If yes, charge and date: |
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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: |
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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 |
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STATEMENT OF UNDERSTANDING
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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.
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Applicant's Signature
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Date
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Spouse Signature
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Date
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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
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