U.S. Adoption Application

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Title of Page

This Field is to be used as an indicator of which form has been submitted. This form is used for International Adoption and International Adoption w Deferred Payment – formerly Waiting Child.

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Parameter: homestudy=yes

The parameter homestudy=yes is set in the Field Values box of each form instance added to a given page. This hides What Type of Adoption under Child Information

This application is a secure form and requires details on medical, finances, relationships and other information. Please plan the proper amount of time to complete the application as thoroughly as possible. A family photo is not required to complete this application, however a photo will be needed later in the process.

Applications are valid for one year from date of receipt. Please have a credit card ready to pay the non-refundable $350 application fee at the end of this form.

Parent 1

Name*

Date of Birth*

Preferred Name

Gender

Male

Female

Other

Parent 2

Name

Date of Birth*

Preferred Name

Gender

Male

Female

Other

Address

Address*

*Show References if the applicant lives in a Branch State: AK, CA, IA, IL, KS, MO, NE, NJ, NY, OR, PA, SD, WA and WI

Length of Time at Current Address*

Phone Numbers

Preferred Number*

Home

Preferred Number Type

Home

Mobile

Work

Parent 1 Mobile

Parent 2 Mobile

Parent 1 Work+Ext

Parent 2 Work+Ext

Parent 1 Email*

Parent 2 Email*

Alternative Contact*

Name and phone number

Marriage

Date of Current Marriage

Parent 1: Previous Marriages*

Marriage 1 Date*

Marriage 1 End Date*

Marriage 2 Date*

Marriage 2 End Date*

Parent 2: Previous Marriages*

Marriage 1 End Date*

Marriage 1 Date*

Marriage 2 End Date*

Marriage 2 Date*

Personal Information: Parent 1

Citizenship*

U.S. Citizen

Non U.S. Citizen

Height: Feet*

Height: Inches*

Weight: Pounds*

Education*

High School / GED

Some College

Bachelor’s Degree

Master’s Degree

Doctorate

Religious Preference

optional

Race/National Origin

optional

Personal Information: Parent 2

Citizenship*

U.S. Citizen

Non U.S. Citizen

Height: Feet*

Height: Inches*

Weight: Pounds*

Education*

High School / GED

Some College

Bachelor’s Degree

Master’s Degree

Doctorate

Religious Preference

optional

Race/National Origin

optional

Children

Please include adult children and those from previous relationships.

Name

Gender

Male

Female

Other

Date of Birth

Lives at Home

Yes, this child lives at home.

Was this child adopted?

Yes, through Holt

Yes, through another agency

Where was your adopted child born?*

Name of Agency or Attorney*

Agency or Attorney Phone*

Placement Date*

Name

Gender

Male

Female

Other

Date of Birth

Lives at Home

Yes, this child lives at home.

Was this child adopted?

Yes, through Holt

Yes, through another agency

Where was your adopted child born?*

Name of Agency or Attorney*

Agency or Attorney Phone*

Placement Date*

Name

Gender

Male

Female

Other

Date of Birth

Lives at Home

Yes, this child lives at home.

Was this child adopted?

Yes, through Holt

Yes, through another agency

Where was your adopted child born?*

Name of Agency or Attorney*

Agency or Attorney Phone*

Placement Date*

Name

Gender

Male

Female

Other

Date of Birth

Lives at Home

Yes, this child lives at home.

Was this child adopted?

Yes, through Holt

Yes, through another agency

Where was your adopted child born?*

Name of Agency or Attorney*

Agency or Attorney Phone*

Placement Date*

Name

Gender

Male

Female

Other

Date of Birth

Lives at Home

Yes, this child lives at home.

Was this child adopted?

Yes, through Holt

Yes, through another agency

Where was your adopted child born?*

Name of Agency or Attorney*

Agency or Attorney Phone*

Placement Date*

Others Currently in Your Home

Who else is in your home?

Please include service personnel, and others living in your home. List up to 5.

Name

Gender

Male

Female

Other

DOB

Age

Relationship

Name

Gender

Male

Female

Other

DOB

Age

Relationship

Name

Gender

Male

Female

Other

DOB

Age

Relationship

Name

Gender

Male

Female

Other

DOB

Age

Relationship

Name

Gender

Male

Female

Other

DOB

Age

Relationship

Employment History: Parent 1

Please provide the last five years

Employer

Current Employer?

Yes

Occupation/Job Title

Gross Annual Salary

Start Month

Start Year

End Month

End Year

Employer

Current

Yes

Occupation/Job Title

Gross Annual Salary

Start Month

Start Year

End Month

End Year

Employer

Current

Yes

Occupation/Job Title

Gross Annual Salary

Start Month

Start Year

End Month

End Year

Employment History: Parent 2

Please provide the last five years

Employer

Current

Yes

Occupation/Job Title

Gross Annual Salary

Start Month

Start Year

End Month

End Year

Employer

Current

Yes

Occupation/Job Title

Gross Annual Salary

Start Month

Start Year

End Month

End Year

Employer

Current

Yes

Occupation/Job Title

Gross Annual Salary

Start Month

Start Year

End Month

End Year

Financial Information

Real Estate Value

Mortgage Balance

Savings

Value of Other Assets

Other Income

Insurance

Parent 1 Medical Insurance

Yes

Parent 2 Medical Insurance

Yes

Adopted children covered by insurance at placement?*

Yes

Adoption Agency

If you’ve already identified an agency or attorney that you’d like to work with for child placement services, please list the name and contact information below.

Name of Agency or Attorney

Phone

*Show References if the applicant lives in a Branch State: AK, CA, IA, IL, KS, MO, NE, NJ, NY, OR, PA, SD, WA and WI

References

Please do not list relatives.

Reference One*

Address

Reference Two*

Address

Reference Three*

Address

Reference Four*

Address

Additional Parent Information

Are you currently receiving treatment for a medical or mental health condition?

Parent 1 Medical Treatment*

Yes

Parent 1 Medical Treatment Description*

Parent 2 Medical Treatment*

Yes

Parent 2 Medical Treatment Description*

Do you have a history of medical issues?

Parent 1 Medical Issues*

Yes

Parent 1 Medical Issues Description*

Parent 2 Medical Issues*

Yes

Parent 2 Medical Issues Description*

Have you ever been arrested, even if it did not result in a conviction or the conviction was expunged? (Please list each arrest, including the year it occurred and the outcome of the charges.)

Parent 1 Arrested?*

Yes

Parent 1 description of arrest*

Parent 2 Arrested?*

Yes

Parent 2 description of arrest*

Children Information

What type of adoption are you planning?*

U.S. Domestic

International

What age of child are you open to adopting at the time of placement?

Check all boxes that apply

Gender Preference

Some programs require families to be open to a child of either gender. And in many countries, more boys need families than girls. What gender of child would you consider adopting?

Any

Male

Female

Would you consider adopting a sibling group?

Yes

How many siblings?

Please enter a number greater than or equal to 2.

Adoption Programs of Interest

Please list in order of preference which of Holt’s adoption program locations you are interested in adopting from. If you write ‘undecided,’ we will happily guide you to the best choice for your family.

Family Photo

Please upload a photo of your family to accompany your application.

Upload Family Photo*

Accepted file types: jpg, jpeg, gif, png, Max. file size: 8 MB.

Sign & Date your Application

We certify the information included in this application is truthful to the best of our knowledge and understand that misrepresentation may be cause for disqualification of our application.

Parent 1 Signature*

Date*

Parent 2 Signature*

Date*

Statement of Understanding

By checking the box below, I verify all applicants are at least 25 years old, a minimum of one applicant is a US citizen and I understand that the application fee is non refundable.

Please check the box below*

I verify

Payment Method

Credit Card Information for your non-refundable $350 application fee

Application Fee

Price:

Credit Card*

Name

This field is for validation purposes and should be left unchanged.

Services to help keep families together

Services and care to help children thrive

Uniting children with families since 1956

Pre Adoption

Parenting Resources

Serving adoptees & families throughout their lives

Post Adoption

Parenting Resources

Supporting children & families around the world

U.S. Adoption Application

Parent 1

Parent 2

Address

Phone Numbers

Marriage

Personal Information: Parent 1

Personal Information: Parent 2

Children

Others Currently in Your Home

Employment History: Parent 1

Employment History: Parent 2

Financial Information

Insurance

Adoption Agency

References

Additional Parent Information

Children Information

Family Photo

Sign & Date your Application

Statement of Understanding

Payment Method