Autobiographical Information Autobiographical Information Adoptive Parent's Information arrowup6 Each adoptive parent must fill out entire form Adoptive Parent's Full Name * Date of Birth * Weight * Height * Hair Color * Eye Color * Adoptive Parent's Father arrowup6 Father's Full Name * Is your father still living? * Yes No Age * Date of Birth * Adoptive Parent's Mother arrowup6 Mother's Full Name * Is your mother still living? * Yes No Age * Date of Birth * Siblings arrowup6 Sibling's Full Name Sibling's Age Sibling's Address Is this sibling married? Yes No Occupation plus1 Add Another Sibling minus1 Remove This Sibling Childhood Experiences arrowup6 What were your feelings toward your parents as you grew up? * Describe your relationship with your siblings during your childhood. * What was it like growing up in your family? * Who was the primary disciplinarian in your family and what type of disciplinary techniques were used? * Discuss any special childhood or adolescent memories including difficult times your family may have faced. * Describe the frequency and amount of alcohol use in your parent’s home and in your home today. * List childhood awards and accomplishments of which you are especially proud. * Describe how you see yourself. * How do you believe others see you? * Discuss three weaknesses you dislike about yourself. * Discuss three strengths you like most about yourself. * Describe your educational, employment and military history including schools attended, degrees earned and your satisfaction with your current job. * What do you do in your leisure time? * What do you regard as your greatest personal achievement to date? * What do you regard as your greatest personal failure to date? * What are your goals in life? * Who contributed most to the formation of your values and personality? * Home and Neighborhood arrowup6 Describe your home, size, number of rooms, sleeping quarters for adopted child. * Location of home (rural, urban etc), surroundings (yard, parks etc) * Description of neighborhood including ethnic composition, whether there are other children * Availability of medical and educational facilities. * Religious Orientation arrowup6 Do you have a religious affiliation? * What is your plan for your child’s religious education? * What are your views regarding philosophical, ethical and spiritual values and their place in rearing children? * Family Mental and Physical Health arrowup6 Do you have a history of medical or psychiatric problems? If so, explain. * If applicable, what are the reasons and your feelings related to childlessness. Adoption arrowup6 What are your motivations for adoption? * What type of child are you seeking to adopt? (age and sex etc.) * What do you understand about the risks and responsibilities you will be undertaking? * What are your plans for helping your child understand his/her background, culture and the reasons s/he was placed for adoption? * How do you think you will cope if your child does not respond to or return affection? * Are you aware of the problems your child might encounter educationally, socially or emotionally at school or in the community? * If you adopt from another country and your child does not speak your language, how do you plan to communicate? * If a difficult situation were to arise with your adopted child, do you have people with whom to share the problem and seek advice? * If there are other children in the home, are they willing to share parents and possessions with a new child? What is the attitude of your extended family to your plans to adopt? * Are you a member of an adoptive parents group? * Guardianship arrowup6 Do you have a plan for your adopted child’s care and support in the event of your death? * Submit