ASAP Pre-Application
Please complete all applicable fields.
Personal Information
Parent 1
First Name *
Last Name *
Occupation *
Date of Birth *
Home Phone *
Cell Phone
Work Phone
E-Mail Address *
Race
Asian
Black
Native American
White
Hispanic
Other/Unspecified
Gender *
Select gender
Female
Male
Parent 2
First Name
Last Name
Occupation
Date of Birth
Cell Phone
Work Phone
E-Mail Address
Race
Asian
Black
Native American
White
Hispanic
Other/Unspecified
Gender
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Female
Male
Address *
City *
State *
Not Applicable
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Zip Code
Marital Status
-- None --
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Single
Married
Widowed
Divorced
Domestic Partnership
Children at Home
Child 1
First Name
Last Name
Date of Birth:
Gender
Select gender
Female
Male
Race:
Asian
Black
Native American
White
Hispanic
Other/Unspecified
Child Origin
Select child origin
Adopted
Biological
Child 2
First Name
Last Name
Date of Birth:
Gender
Select gender
Female
Male
Race:
Asian
Black
Native American
White
Hispanic
Other/Unspecified
Child Origin
Select child origin
Adopted
Biological
Child 3
First Name
Last Name
Date of Birth:
Gender
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Female
Male
Race:
Asian
Black
Native American
White
Hispanic
Other/Unspecified
Child Origin
Select child origin
Adopted
Biological
Child 4
First Name
Last Name
Date of Birth:
Gender
Select gender
Female
Male
Race:
Asian
Black
Native American
White
Hispanic
Other/Unspecified
Child Origin
Select child origin
Adopted
Biological
Child 5
First Name
Last Name
Date of Birth:
Gender
Select gender
Female
Male
Race:
Asian
Black
Native American
White
Hispanic
Other/Unspecified
Child Origin
Select child origin
Adopted
Biological
Child 6
First Name
Last Name
Date of Birth:
Gender
Select gender
Female
Male
Race:
Asian
Black
Native American
White
Hispanic
Other/Unspecified
Child Origin
Select child origin
Adopted
Biological
What characteristics in a child would best fit your family
Gender
Select gender
Girl Only
Boy Only
Either Sex
Race
Asian
Black
Native American
White
Hispanic
Other/Unspecified
Age Range
New born under 6 months
Baby/Toddler (6-24 months)
Preschool (24-48 months)
Medical Issues
Moderate non-correctable medical problems, such as some congenital anomalies and some syndromes.
Severe medical problems, such as: medically fragile, more severe cerebral palsy, shortened life span and multiple handicaps.
Extreme prematurity (26 weeks and under). Birth weight under 2 lbs. 8 oz.(Significantly increased risk for physical and neurological issues.)
Likely moderate cognitive disabilities—not Down syndrome
Down syndrome
Down syndrome with cardiac or other significant medical involvement
Brain anomolies- outcome uncertain
Anticipated severe to profound cognitive disabilities
Potential for serious and lifelong alcohol-related disabilities due to significant prenatal exposure to alcohol
Significant heavy use of drugs by birth mother—Child at risk for behavior, attention, learning and other challenges. (In these circumstances, alcohol use cannot be ruled out.)
Infant currently exhibiting atypical neurological development (e.g. hypertonicity, tremors, fisting) etiology is unknown. May significantly increase risk for neurological and behavorial issues as the child matures.
Child at risk for mental illness—one birth parent with psychiatric disorder
Child at risk for mental illness—both birth parents with psychiatric disorder
Other issues (Please note in comments section)
Legal Risk Placement
Yes
No
Case by case
Home Study Agency
Name of Agency
Current Case Worker
Telephone
Ext
Comments
Other specific physical issues with which you are comfortable:
Other specific mental/cognitive issues with which you are comfortable:
Additional Comments:
Experience
What, if any, experience do you have caring for children with special needs?
More About Your Family
Is there anything else you wish to tell us about yourself and/or your family?
Choosing Spence-Chapin
Referral Source *
--- Select ---
Conference/ Workshop
Internet
Magazine
Adoptive Parent
Reputation/ Friend
Other/Network Agency
Newspaper
Other
TV/Radio
Yellow Pages
None of the Above
Referral Sub Source
--- Select ---
If Other