Family Registration Form Posted March 22, 2015 by pacadmin Family Registration Form Step 1 of 5 20% Applicant #1 First Last DOB GenderMaleFemaleOccupationWork PhoneHighest grade completedPlease select oneNo formal schoolingHigh school equivalency (eg. GED)High schoolPost-secondary VocationSome collegeAssociate DegreeBachelor DegreeGraduate DegreeWork StatusFull-timePart-timeFlexible scheduleCell PhoneEmail Applicant #2 First Last DOB GenderMaleFemaleOccupationWork PhoneHighest grade completedPlease select oneNo formal schoolingHigh school equivalency (eg. GED)High schoolPost-secondary VocationSome collegeAssociate DegreeBachelor DegreeGraduate DegreeWork StatusFull-timePart-timeFlexible scheduleCell PhoneEmail Address Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code CountyMarital StatusSingleMarried/Civil PartnerDivorcedWidowedSeparatedNot disclosedReligionLanguage SpokenSign LanguageYesNoPets in home (# and kind)Are there smokers in the home?YesNo Please check all that apply for each child living in the home:Child 1First Name Child 1 First BiologicalYesNoAdoptedYesNoFosterYesNoMental Physical/Emotional Challenges Child 2First Name Child 2 First BiologicalYesNoAdoptedYesNoFosterYesNoMental Physical/Emotional Challenges Child 3First Name Child 3 First BiologicalYesNoAdoptedYesNoFosterYesNoMental Physical/Emotional Challenges Child 4First Name Child 4 First BiologicalYesNoAdoptedYesNoFosterYesNoMental Physical/Emotional Challenges Child 5First Name Child 5 First BiologicalYesNoAdoptedYesNoFosterYesNoMental Physical/Emotional Challenges Child 6First Name Child 6 First BiologicalYesNoAdoptedYesNoFosterYesNoMental Physical/Emotional Challenges Child 7First Name Child 7 First BiologicalYesNoAdoptedYesNoFosterYesNoMental Physical/Emotional Challenges Please check all types of children you would consider adopting:Preferred Race Any African American Asian Biracial Caucasian Hispanic Native American Other Preferred SexFemaleMaleEitherPreferred Age Any age 0-6 7-10 11-14 15 and over How many at this time? Any number One Two Three Four The youngest age child I will consider is?The oldest age child I will consider is?Are you interested in sibling groups?YesNo Please check the following challenges that you will consider in a child: Attachment Disorder Autism Bi-polar Blind Cerebral Palsy – Mild Cerebral Palsy – Moderate Cerebral Palsy – Severe Conduct Disorder Deaf Depression Developmental Delays Diabetes Down Syndrome Drug Exposed Eating Disorders Emotional - Mild Emotional – Moderate Emotional – Severe Encopresis Hyperactivity Learning Disability Legal Risk Macro cephalic Mental Retardation – Mild Mental Retardation – Moderate Mental Retardation – Severe Micro cephalic Missing Limbs Mood Disorder Muscular Dystrophy Non-Ambulatory Non-Verbal Obsessive Compulsive Disorder Oppositional Defiant Disorder (ODD) Paralysis Physically Abused Physically Aggressive Post-Traumatic Stress Disorder (PTSD) Self-Abuse Sexually Abused Sexually Acting Out Shaken Baby Syndrome Sickle Cell Spinal Bifida Terminal Illness Total Care Tourette Syndrome Trach Tube Fed Other Conditions, Syndromes, Problems (Please List) OtherAre you willing to attend specialized training if needed?YesNoAre you willing and/or able to participate in the child's treatment and/or therapy as needed?YesNoAre you willing to allow child to maintain contact with siblings, relatives, etc. if it is in this/her best interest?YesNoDescribe any skills, knowledge, or experience with special needs children you may have: Describe any conditions or behaviors you cannot accept (including any areas that you know would not be a good fit for your family: Please give us a brief description of your family, your lifestyles, your interests, etc.: Do you have an approved home study and have you been approved for adoption?YesNoName of AgencyAddress of Agency Street Address Address Line 2 City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Agency Contact Name Contact PhoneUpload Home StudyUpload picture of familyThis form will be sent by email to several Harmony staff for review prior to upload on the websiteEmailThis field is for validation purposes and should be left unchanged.
