Baker Victory Services – Pre-application |

Baker Victory Services
New York State Authorized Adoption Agency
FANA – Colombia Program

ALL INFORMATION COLLECTED ON THIS FORM IS STRICTLY CONFIDENTIAL
(Fields marked with “*” are required)

Contact Information:

Family Name *

Address *

City *

State *

Postal Code *

Telephone *

E-mail Address *

Home and Family:

Date of Marriage

Do you rent or own? *

Number of Rooms *

Value of Home *

Amount of mortgage *

Children

References *

Husband:

Husband - Full Name *

Husband - Date of Birth, Place and Ethnicity *

Husband - Religion *

Husband - Previous Marriages

Husband - Height/Weight *

Husband - Education *

Husband - Current Employer *

Husband - Health

Husband - Have you been treated for chemical dependency?

Husband - Have you ever been arrested/fingerprinted?

Husband - Have you ever been convicted of a felony or DWI?

Husband - Details

Wife:

Wife- Full Name *

Wife - Date of Birth, Place and Ethnicity *

Wife - Religion *

Wife - Previous Marriages

Wife - Height/Weight *

Wife - Education *

Wife - Current Employer *

Wife - Health

Wife - Have you been treated for chemical dependency?

Wife - Have you ever been arrested/fingerprinted?

Wife - Have you ever been convicted of a felony or DWI?

Wife - Details

Adoption:

Reason for adoption: *

Other Adoption Opportunities:

Age preference of the child you wish to adopt?

Special Needs situations you would consider:

Older Children (not babies)

Sibling Groups

Correctable or Non-Correctable Involvement

Country and Agency restrictions may be more flexible on behalf of "special needs" children.

Special Needs Opportunities

Would you be able to act quickly if such an opportunity became available?

How did you hear about this program?

SPAM Prevention

THE ACCEPTANCE OF YOUR APPLICATION TO ADOPT IS NOT A CONTRACTUAL OBLIGATION IMPLIED OR OTHERWISE TO PLACE A CHILD WITH YOU.

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