(LSWDOs LOGO)
APPLICATION FORM
Prospective Adoptive Parent
Please check appropriate box:
Regular
Relative
Independent
IDENTIFYING INFORMATION:
Prospective Adoptive Prospective Adoptive
Father Mother
Name
Age
Date of Birth
Place of Birth
Nationality/Citizenship
Religion
Home Address
Telephone Number/CP Number
E-mail address
Marital Status
If married, date of Marriage
Place of Marriage
Date of Previous Marriage, if any
Manner by which marriage was
terminated; state branch and
number of years
Military services; state branch and
number of years
Membership in
Association/Clubs/Organization
ECONOMIC DATA:
Prospective Adoptive Prospective Adoptive
Father Mother
Occupation
Name of Employer
Business Address
Office Telephone No.
Email Address
Income other than salary
Real Properties
Savings
Insurance
Loan/Debts
EDUCATION
Prospective Adoptive Prospective Adoptive
Father Mother
Elementary
Year Graduated
Honors Received
Name & Location of school
Secondary
Year Graduated
Honors Received
Name & Location of school
College
Year Graduated
Honors Received
Name & Location of school
Graduate School
Year Graduated
Honors Received
Name & Location of school
EMPLOYMENT HISTORY
Prospective Adoptive Prospective Adoptive
Father Mother
Position:
Employer:
Reason & Year of separation from
the company
Position
Employer
Reason & Year of separation from
the company
HOUSEHOLD MEMBERS:
A. List of all individuals living with the couple in present address:
Name Age Sex Relationship Educational Disability
Attainment /Illness, specify
1.
2.
3.
HOUSEHOLD MEMBERS:
A. List of children of either couple/living away from them, if any:
Name Age Sex Relationship Educational Disability
Attainment /Illness, specify
1.
2.
3.,
Have you applied before to adopt a child? If so, where did you file your Application?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
What are your reason/s for adopting?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
For relative/independent adoption, indicate circumstances, date when you got actual
custody of the child.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Do you have any illness or handicap which may affect the care of the child?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
What are your feelings about the child knowing his/her biological parents?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Child preference: (Please state the gender and age of a child you want to adopt)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Are you willing to adopt a child with special needs? (Ex. Cerebral palsy, epilepsy, with
autism, etc.)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Please state your plan/s to the child you wish to adopt.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
What changes or adjustment will you make once the child has been placed to your
home? (Ex. Time of work and organization)
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
What is your reaction if the social worker interviews your children, relatives, friends and
employer?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Who may be contacted for more information on your character? (Please do not include
relatives)
Name Relation to Applicant/s Address & Contact
Numbers
___________________________ ___________________________
Prospective Adoptive Father Prospective Adoptive Mother
(Signature Over Printed Name) (Signature Over Printed Name)
__________________________ ___________________________
Date Date
__________________________
Social Worker In-charge
