THE CROSSNORE SCHOOL ADOPTION PLACEMENT PROGRAM. Every child deserves a Forever Family ADOPTIVE HOME APPLICATION

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1 THE CROSSNORE SCHOOL ADOPTION PLACEMENT PROGRAM Every child deserves a Forever Family ADOPTIVE HOME APPLICATION The Crossnore School PO Box 249 Crossnore, NC Phone: (828) Fax: Website: Rosalia Bealer Director of Adoption Services (PLEASE PRINT) NAME LAST FIRST MIDDLE NAME LAST FIRST MIDDLE PHONE NUMBER ADDRESS DATE OF APPLICATION Date application received: OFFICE USE ONLY FAMILY Adoption PROFILE: Placement Program Statement Signed? Yes No

2 Prospective Parent #1 Prospective Parent #2 Name List all first and last names used Social Security # Date of Birth/Age Race/Ethnicity Sex Hours of Work Highest Grade Completed Marital Status If married, Date and Place of Marriage Previous Marriages Yes/No Date of Divorce Yes/No Date of Divorce Home address: Home telephone: Directions to your home (you may attach internet directions if needed):

3 PLEASE ATTACH RECENT PHOTO OR PHOTOS OF YOURSELF AND YOUR HOME ADDITIONAL PHOTOS

4 EMPLOYMENT HISTORY FOR PERSPECTIVE PARENT #1: Please give accurate, complete full-time and part-time employment record. Start with your present or most recent employer. Please complete each section even if submitting a resume

5 EMPLOYMENT HISTORY FOR PERSPECTIVE PARENT #2: Please give accurate, complete full-time and part-time employment record. Start with your present or most recent employer. Please complete each section even if submitting a resume

6 QUESTIONS ABOUT ADOPTION: Please state your preference as to the sex and age of the child or children you wish to adopt: Sex: Age Range: Where would child or children sleep? Would you consider siblings? Yes No How many? Have you previously adopted a child? Agency: Year: Have you previously applied to another agency to adopt? Agency: How did you learn about The Crossnore School Adoption Placement Program? Newspaper Presentation Direct Mail Radio TV Word of Mouth Other: Why are you interested in becoming an adoptive parent? OTHERS IN THE HOME: Name DOB/ Age Sex Race/ Ethnic Occupation/ School Grade Relationship to Prospective Parent 1 (birth, foster, adoptive, in-law) Relationship to Prospective Parent 2 (birth, foster, adoptive, in-law)

7 CHILDREN LIVING AWAY FROM HOME: Name DOB/ Age Name of School Or Employment Specify relationship if not biological ASSETS: List savings, investments, personal property valuation and real estate: DEBTS: (Other than home) INSURANCE: Life: Hospitalization: HOME: Owned: Rented: Monthly payment: If owned, value: Mortgage: PERSONAL INFORMATION: Has Prospective Parent #1/Prospective Parent #2 ever been treated for emotional and/or serious physical problems? Yes No If yes, please state when, where and nature of illness: Has Prospective Parent#1/Prospective Parent #2 ever been charged or convicted of a crime? Yes No If yes, please give details or explanation: Has Prospective Parent #1/Prospective Parent #2 ever been in treatment for alcohol or drug abuse? Yes No

8 REFERENCES FOR PERSPECTIVE PARENT #1: NAME COMPLETE ADDRESS 3 non-related references are required. PHONE/FAX NUMBER OCCUPATION RELATIONSHIP/HOW LONG KNOWN? REFERENCES FOR PERSPECTIVE PARENT #2: 3 non-related references are required. NAME COMPLETE ADDRESS PHONE/FAX NUMBER OCCUPATION RELATIONSHIP/HOW LONG KNOWN? Please attach a copy of your Marriage Certificate (or termination of marriage documentation) and the most recent Medical Examination for husband, wife, and any other family members living in the household. APPLICANT S CERTIFICATE AND RELEASE (Read Carefully Before Signing) We/I, the undersigned applicant/s, understand that: 1. NC state law requires criminal background checks of prospective adoptive parents seeking to adopt a minor who is in the custody of a County Department of Social Services. 2. All information provided by us/me in support of our/my Adoptive Home Application is true and correct to the best of our/my knowledge. We/I understand that misrepresentations or omissions may be cause for rejection of this application. 3. We/I hereby authorize any current or former employer, person, firm, corporation or government agency to answer any and all questions and to release or provide any information within their knowledge or records, and we/i agree to hold any or all of them blameless and free of any liability for releasing any truthful information that is within their knowledge or records. 4. This application places no commitment upon The Crossnore School or us/me. Prospective Parent #1 Signature Prospective Parent #2 Signature Date

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