Alaska International Adoption Agency. Adoption Application Form. Adoption application questionnaire.

ADOPTION APPLICATION

1. Please fill out information as it states on your Passport If you don't have a passport yet you may apply without it.
Father	Mother
First Name: Middle Name: Last Name: Date of Birth (mm/dd/yy): Passport #: Passport Expiration Date (mm/DD/yy):	First Name: Middle Name: Last Name: Date of Birth (mm/DD/yy): Passport #: Passport Expiration Date (mm/DD/yy):

2. Occupation information
Father	Mother
Full Name of the Company: Company Address: Address: Address: City: State: Zip: Phone: Fax: Email:	Full Name of the Company: Company Address: Address: Address: City: State: Zip: Phone: Fax: Email:

3. Full physical address with Zip Code
Address:		Date of Marriage: (mm/DD/yy)
Address:		Place of Marriage:
City:		Yearly taxable income reported on most recent Federal income tax return:
State:
Zip Code:	-
Phone:
Email:
Children at home and their age:

	Father	Mother
4. Any health issues for adoptive parent?
5. Are you under a doctor's care for any ongoing condition?
6. Do husband or wife have any chronic health issues?
7. Do husband or wife have any history in any of the following categories?	Father	Mother
7.1 Addictions
7.2 Learning Disorders
7.3 Allergies
7.4 Mental Illness
7.5 Blood Disease
7.6 Neurological Disorders
7.7 Cancer
7.8 Respiratory Disorders
7.9 Cardio-Vascular Disease
7.10 Sexually Transmitted Disease
7.11 Endocrine Disorders
7.12 Skeletal Problems
7.13 Gastro-Intestinal Disorders
7.14 Skin Problems
7.15 Hearing Defects
7.16 Urogenital Disorders
7.17 Visual Defects
7.18 Depression

8. Do you have any police record?
a. do you have any record with police for any matter other than minor traffic (note: this does not preclude adoption under US law, but could be restrictive under foreign regulations)
b. have you been involved in litigation in the past 5 years?

9. Why do you wish to adopt a child at this time?
10. Do you know anybody who has adopted recently?
11. Why do you wish to adopt from a foreign country?
12. Why do you wish to adopt from Russia ?
13. Are you both ( you and your spouse) equally committed to adoption?
14. Will your relatives, and other members of your family accept an adopted child?
15. Child desired	Gender: Age: Other criteria:
16. Would you accept a child with minor, correctable condition?
a. cross-eyes (example)
b. other (please specify)
17. Would you accept a child with other correctable or non-correctable conditions
a. cleft palate (example of correctable)
b. cerebral palsy in light form ( example of non-correctable condition)
18. Sometimes referrals are made of abandoned children for which no information is available on their social or medical background. Are you willing to consider adopting such children?
19. Have you evaluated your health insurance policies to ensure they will adequately cover an adopted child?
20. Have you prepared a plan of care for your adopted child to meet unanticipated contingencies, such as illness of a spouse, need to care for a parent, illness of the adopted child, or crisis event?
21. Do you have a completed Homestudy?
22. Home Study Agency Information	Name of the agency: Contact person at the agency Address: Address: City: State: Zip: Phone: Fax: Email:
23. Do you have USCIS approval?
24. Any Comments:
25. How did you hear about us?

Please email us if you have any questions completing this form.