VIDA Background Information Form
email form coming soon
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.
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