ADOPTION PRE-APPLICATION

As you move forward in your adoption process, we want you to know how deeply AGCI cares for your family and your well being. We have created this free pre-application in order to provide you with the highest level of service to ensure your adoption process is a success. Due to differing country criteria, this pre-application is a tool that allows AGCI staff to determine the best program that fits your family's needs. Upon review and approval of this pre-application, our staff will assist you in completing and submitting your formal adoption application.

PLEASE NOTE: If you are a single parent, please put n/a in the appropriate missing spouse information fields.

Click here to download the PDF version of this application to submit.

GENERAL INFORMATION

Address:
Town/City:
State:
Zip Code:
Home Phone:
Primary Email:

ADOPTIVE MOTHER First Name: Middle Initial: Last Name: Work Phone: Mobile Phone Email Address: Date of Birth: Age: Country of Citizenship: Select Australia Austria Bahamas Belgium Brazil Bulgaria Canada China Cyprus Czech Republic Denmark Egypt Estonia Finland France French Polynesia Germany Greece Hungary India Indonesia Ireland Israel Italy Jamaica Japan Kenya Latvia Lebanon Lithuania Luxembourg Malta Mexico Netherlands New Zealand Phillippines Poland Portugal Romania Saudi Arabia Singapore Slovakia Slovenia South Africa Spain Sudan Sweden Switzerland Taiwan Tonga Turkey United Arab Emirates United Kingdom United States Vietnam Height: Weight: Occupation: Annual Income: Religious Preference:

ADOPTIVE FATHER First Name: Middle Initial: Last Name: Work Phone: Mobile Phone: Email Address: Date of Birth: Age: Country of Citizenship: Select Australia Austria Bahamas Belgium Brazil Bulgaria Canada China Cyprus Czech Republic Denmark Egypt Estonia Finland France French Polynesia Germany Greece Hungary India Indonesia Ireland Israel Italy Jamaica Japan Kenya Latvia Lebanon Lithuania Luxembourg Malta Mexico Netherlands New Zealand Phillippines Poland Portugal Romania Saudi Arabia Singapore Slovakia Slovenia South Africa Spain Sudan Sweden Switzerland Taiwan Tonga Turkey United Arab Emirates United Kingdom United States Vietnam Height: Weight: Occupation: Annual Income: Religious Preference:

MOTHER'S MARRIAGE (if applicable) Date of marriage: Number of Previous Marriages: Select 0 1 2 3

FATHER'S MARRIAGE (if applicable) Date of marriage: Number of Previous Marriages: Select 0 1 2 3

MOTHER'S HEALTH INFORMATION Are you currently under a physician's care? Select Yes No Do you have a history of medical issues? Select Yes No Please list all current/past medical treatments. Include any medications and/or hospitalizations: Have you ever been treated for cancer? Select Yes No If so, have you been in remission for at least 5 years? Select Yes No NA Do you have a history of mental illness (ie. anxiety, depression, etc.)? Select Yes No Please include a brief statement on mental health to include any current or past medications and/or hospitalizations: If so, are you currently taking medication? Select Yes No Are you currently seeing a counselor? Select Yes No Please include current or past counseling and include why counseling was sought and the outcomes: Have you experienced Infertility Assistance, a miscarriage or a loss of a child? Select Yes No If yes, please include a brief statement: Have you experienced physical or sexual abuse? Select Yes No If yes, please include a brief statement:

FATHER'S HEALTH INFORMATION Are you currently under a physician's care? Select Yes No Do you have a history of medical issues? Select Yes No Please list all current/past medical treatments. Include any medications and/or hospitalizations: Have you ever been treated for cancer? Select Yes No If so, have you been in remission for at least 5 years? Select Yes No NA Do you have a history of mental illness (ie. anxiety, depression, etc.)? Select Yes No Please include a brief statement on mental health to include any current or past medications and/or hospitalizations: If so, are you currently taking medication? Select Yes No Are you currently seeing a counselor? Select Yes No Please include current or past counseling and include why counseling was sought and the outcomes: Have you experienced Infertility Assistance, a miscarriage or a loss of a child? Select Yes No If yes, please include a brief statement: Have you experienced physical or sexual abuse? Select Yes No If yes, please include a brief statement:

MOTHER'S CRIMINAL INFORMATION Have you ever been arrested? Select Yes No Have you ever been convicted of a misdemeanor? Select Yes No Have you ever been convicted of a felony? Select Yes No Do you have a history of substance abuse? Select Yes No Please include information on any of the above criminal or substance abuse issues:

FATHER'S CRIMINAL INFORMATION Have you ever been arrested? Select Yes No Have you ever been convicted of a misdemeanor? Select Yes No Have you ever been convicted of a felony? Select Yes No Do you have a history of substance abuse? Select Yes No Please include information on any of the above criminal or substance abuse issues:

CHILDREN INFORMATION

	Name:	Birth Date:	Age:	Gender:	Adopted:	Living with you:
Child 1				Select Male Female	Select Yes No	Select Yes No
Child 2				Select Male Female	Select Yes No	Select Yes No
Child 3				Select Male Female	Select Yes No	Select Yes No
Child 4				Select Male Female	Select Yes No	Select Yes No
Child 5				Select Male Female	Select Yes No	Select Yes No
Has any of your children experienced physical or sexual abuse? Select Yes No If yes, please include a brief statement:

ADDITIONAL INFORMATION

Total Assets			Total Liabilities
Do you currently have any other relative(s) or non relative(s) living in your home? Select Yes No

Which program(s) are you interested in applying?
Yes No Bulgaria	Yes No China	Yes No Ethiopia	Yes No India	Yes No Nepal	Yes No Oregon Foster Care

Gender of Child: Select Male Female No Preference		Preferred Age Range: Select 0-12 1-3 4-6 7-Up
Would you be open to a waiting child? Select Yes No		Would you consider siblings? Select Yes No
Will your health insurance cover a child with pre-existing conditions upon child's placement with your family? Select Yes No

Have you previously adopted through AGCI?	Select Yes No	If yes, which program:			Select Albania Bulgaria China Ethiopia Guatemala Hungary India Kazakhstan Oregon Romania Russia Ukraine Vietnam
Do you currently have a family member adopting through AGCI?	Select Yes No	If yes, family name:
Have you requested an Information Packet?	Select Yes No	If yes, when:
How did you hear about AGCI?
Yes I want access to the Waiting Children Photo Listing