VIDA Background Information Form Date:______________________ General Information Name Wife/Single Applicant _____________________________________________ Name Husband ________________________________________________________ Address: __________________________________________________________ _________________________________________________________________ Phone-day(wife/single) ________________day(husband)___________________ Evening_______________________ Fax:__________________________ E-Mail:_____________________________________________________ Wife/Single Applicant Information Age ____ Citizenship_________ Health (indicate any special conditions ie: are you currently being treated for or a history of medical or psychiatric condition if so-explain) ________________________________________________________________ Profession_______________________ Employer___________________________ Do you have a criminal history? ______________ Explain_______________________________________________________ ‘ Husband Information Age:_________Citizenship_________Health (indicate any special conditions ie: are you currently being treated for or a history of medical or psychiatric condition if so-explain) __________________________________________________________________ Profession_______________________ Employer___________________________ Do you have a criminal history? ______________ Explain_______________________________________________________ ‘ Marital Status Are you married or Single?___________ If married, what is the date of your marriage?_________ Do you have any previous marriages?___________________________________ ‘ Children in the Home: Do you have any children in the Home?_________ If yes, please complete the information below. Name of Child Age Biological Adopted _____________________ ______ _________ __________ _____________________ ______ _________ __________ _____________________ ______ _________ __________ _____________________ ______ _________ __________ If any of your children are adopted, please tell us from where, when, and through what agency: _______________________________________________________________ _______________________________________________________________ ‘ Documentation Some applicants may have already begun completing part of the documentation required. If you have begun, please fill out the requested information below. USCIS Application: In progress?_____ Completed?____ Date completed ___________ Home Study: In progress?_____ Completed?____ Date completed ___________ If completed, name of social worker and agency ______________________________________ ________________________________________________________________________ ________________________________________________________________________ ‘ VIDA Referral How did you learn about VIDA? Please check all that apply. Family who had adopted from VIDA (please name family)________________________ _____ Agency/Social Worker referral(please name referral source) _____ Ad (please name source) _____ Information Meeting(name location) _____ Internet Other source______________________ Travel Are you willing to travel: Yes_____ No_____ If yes, how many weeks can you spend in your child's country?____________________ ‘ Applicant(s) Statement Please attach a brief description of yourself(selves), your motivation to adopt, and your expectations of adoptions. Please also share with us a little information about the child(ren) you hope to adopt. Feel free to elaborate on any of the considerations presented in this form. This information helps us to know more about you and enables VIDA to be of a greater assistance during the adoption process. ‘ Child Considerations Please tell us a little about the child(ren) you hope to adopt. Child's Age: Do you have a preference regarding the age of the child? yes____ no____ If yes, please complete the section below and identify you first and second preferences. Newborn(birth to 6 months)______ Infant(7-18 months)______ Toddler(19 months-3 years) ______ Preschooler(4-5 years)______ Young Child(6-8 years) _______ Older child(9-15 years)______ Number: Would you consider more than one child? yes____ no____ Would you consider siblings? yes____ no____ Sex of Child: Did you have a preference regarding the child's sex? yes___ no___ If yes, check your preference: BOY______ GIRL______ Health Consideration: Please tell us about your health considerations. Are you willing to consider a healthy child? yes_____ no_____ Would you consider a child with special needs? yes_____ no_____ If yes, complete the section below indicating the type of special needs you would consider. Correctable Minor condition______ Correctable Major condition______ Non-correctable, minor condition_____Non-correctable, major condition_____ Any child who needs us_____ Race: Is the child's race an important consideration? Yes_____ no_____ If yes, please tell us about your concerns ____________________________ ‘ Adoption Considerations. Check the programs that reflect your interest. Please note that the process may differ from Hague to non-Hague countries. The US, UK and EU countries are Hague countries. At this time (October 2008) the countries that are Hague, which VIDA considers, are listed with an (H) attached. It is also important to note that some of the countries listed may later close or be closed at this time. We will notify you of the status of adoption in the country you are considering at the time we receive this completed form. International adoption___ U.S. adoption(H)_____ No preference yet_____ Latin America Guatemala (Development work only (H)___ Honduras___ El Salvador(H)___ Asia Philippines (H)___ China(H)___ Japan_____ Taiwan (special needs)____ Eastern Europe Russia___ Lithuania(H)___ Bulgaria (H) ______ Armenia (H) (special needs) _____ United States Waiting Children (H)______Infants (H)______ Are you prepared to cooperate with 2 to 4 years of follow-up requirements? yes___ no____ NOTE Your eligibility for each program may be affected by country requirements and your nationality, country of residence and where you currently reside.