Hand in Hand

Registration

There is no fee to submit this form, and you will be under no obligation. We will send you some additional information, an application, and if you are located in Arizona, Colorado, Florida, Indiana, or Minnesota, the dates of our next free informational orientation meetings. If you live outside of Arizona, Colorado, Florida, Indiana, or Minnesota and would like some assistance in locating a Home Study agency within your state, please contact us. All children are placed for adoption in accordance with the laws and requirements of the child's country of birth.

— Applicant Information —

Prospective Father’s Full Name:
Prospective Mother’s Full Name:
Maiden Name:
Street Address:
City, State, Zip:
Daytime Telephone:
Evening Telephone:

— Contact Information —

	His	Hers
E-mail address
Date/Place of birth
Country of Citizenship
Occupation
Education (years completed)
Health

Date/Place of current marriage
Previous marriage(s) (Provide Dates)

— Children in the Family —

Name	Date of Birth	M	F	Adopted

— Questionnaire —

Do you have a current home study? If so, give name and address of agency

Preferred age range of child (check all that apply)
   birth - 12 months        1yr - 2yrs
      2-4 years 4-8years        8-12 years        12 and older

Which countries are you interested in adopting from (check all that apply):
Russia Ukraine China
Philippines Haiti Guatemala

Which races would you consider in an adoptive child? (check all that apply):
Caucasian Hispanic Asian Black Gypsy
European Black/Asian Black/Caucasian Black/Hispanic

Which medical conditions would you consider discussing (check all that apply):
Premature      Crossed eyes         Cleft lip/palate        Partial hearing loss
Malnutrition         Gross motor delay        Speech delay        Heart Murmur
Hernia     Parasites      Positive TB screen        Club foot      Tooth decay

Are you near to any of the following Hand In Hand offices?
Fort Collins , CO Albion, IN Tucson, AZ Mesa, AZ
St. Paul, MN Ocala, FL None