A Caring Connection-Adoption Services
Adoption Application
A Caring Connection of Catholic Charities
INITIAL ADOPTION QUESTIONNAIRE
Name:____________________________________Name:_______________________________________
Address:______________________________________________________County__________________
City, State:________________________________ Zip Code:______
How long at this address:__________Home Phone:_______________
Cell Phone #'s:__________________________E-Mail:___________
Date/Place of Marriage:___________________________________________________
Husband Wife
Work Phone:____________________ _____________________
Employer: ____________________ _____________________
Occupation: ____________________ _____________________
Education: ____________________ ______________________
Income: ____________________ ______________________
Birthdate: ____________________ ______________________
Birth Place: ____________________ ______________________
Religion: ____________________ ______________________
Race: _____________________ ______________________
Hair Color: _____________________ ______________________
Eyes: _____________________ _____________________
Height: _____________________ ______________________
Do you have any children?yes____no____If so,list their dates of birth ___________
Have you or your spouse been divorced?yes____no____Number of times and dates:____________________
Have you or your spouse been charged or convicted of a crime in the past ten years which has not been annulled, expunged or sealed by a court? yes____ no____
Have you ever applied for adoption through another agency? yes____ no____
Were you approved by that agency? yes___ no____ Name of agency:________________
Eligibility Requirements for Entrance into the Adoption Program
1. Residency: You must reside in the Diocese of Lexington, Kentucky for one (1) year prior to application. This comprises the counties of Anderson, Bath, Bell, Bourbon, Boyd, Boyle, Breathitt, Carter, Clark, Clay, Elliott, Estill, Fayette, Floyd, Franklin, Garrard, Greenup, Harlan, Jackson, Jessamine, Johnson, Knott, Knox, Laurel, Lawrence, Lee, Leslie, Letcher, Lincoln, McCreary, Madison, Magoffin, Martin, Mercer, Menifee, Montgomery, Morgan, Nicholas, Owsley, Perry, Pike, Powell, Pulaski, Rockcastle, Rowan, Scott, Wayne, Whitley, Wolfe and Woodford.
2. Children: Couples who already have children must wait until the youngest child is at least one (1) year of age before being eligible to apply to adopt subsequent children from our agency.
3. Marriage: You must be married at least three (3) consecutive years to the same person prior to application. Persons divorced more than once will not be considered.
4. Health: You must have the usual life expectancy.You must be able to reliably attend to the care of children and demonstrate emotional stability.
5. Infertility: You must have explored medical solutions and have substantially resolved related psychological issues. Adoption is reserved for those couples who have not been able to have their own biological children even though no medical reason may be found yet as to why they cannot conceive. If you are choosing to adopt a child rather than have your own, we cannot serve you for adoption.
6. Income: You must demonstrate financial security by meeting the requirements established for Catholic Charities-Diocese of Lexington, Kentucky’s Bureau’s adoption program.
7. Age: Each member of a couple must be between the ages of 25-47 years old at the time of application to our adoption program
**In the case of children needing special placement, the ordinary requirements for admission to the adoption program may be waived in whole or in part at the agency's discretion.
Do you and your spouse meet the eligibility requirements listed on this form? yes_____no_____
If no, please explain:______________________________________________________
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Please describe the type of child that you are interested in adopting:_________________________________________________
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___________________________ ___________________________ Husband's Signature Date Wife's Signature Date