Domestic Adoption Inquiry Considered a pre-application Please include a family photo with your submission* Drop files here or Select files Accepted file types: jpg, png, pdf, , Max. file size: 50 MB. DateMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920A. Identifying DataName (Applicant #1) First Last Name (Applicant #2) First Last Address Mailing Physical (if applicable) City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone Home Cell (Applicant #1) Cell (Applicant #2) Email Addresses Preferred Method of Contact B. Personal DataEthnic Background Applicant #1 Applicant #2 Height/Weight Applicant #1 Applicant #2 Age and Birthplace (including County) Applicant #1 Applicant #2 Date of marriage/Length of Relationship Applicant #1 Applicant #2 Education Level Applicant #1 Applicant #2 Occupation/Employer Applicant #1 Applicant #2 Gross Annual Income Applicant #1 Applicant #2 Religious Affiliation Applicant #1 Applicant #2 Health Status Applicant #1 Applicant #2 Citizenship Applicant #1 Applicant #2 C. All Children in/out of Household (including any adult children)Name Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex Male Female Race Biological/Adopted (if adopted, date of adoption)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex Male Female Race Biological/Adopted (if adopted, date of adoption)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex Male Female Race Biological/Adopted (if adopted, date of adoption)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Name Date of BirthMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex Male Female Race Biological/Adopted (if adopted, date of adoption)Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920D. Child DesiredThis is a screening tool and is not intended to be binding.I. ETHNICITY (Please check all that you are open to) Anglo Hispanic African American Asian American Indian Anglo/Hispanic Anglo/ African American Anglo/Am Indian African American/Hispanic African American/Asian All Other (specify) II. AGE AND NUMBER OF CHIDLREN ACCEPTABLE 0-3 months 3-6 months 7-12 months Twins Number of Children Acceptable Acceptable Background (Y = Yes; N = No; D = Willing to Discuss)Family BackgroundUnknown Father Y N D Limited information about Father Y N D Incest Y N D Rape/Acquaintance Rape Y N D Intellectual Disability (Parent) Y N D Intellectual Disability (Family) Y N D Mental Illness (Parent) Y N D Mental Illness (Family) Y N D Birthmother During PregnancyMarijuana Usage Y N D Hard Drug Usage Y N D Prescription Drug Use Y N D Alcohol Usage Y N D Smoking Y N D HIV positive Y N D Limited or no prenatal care Y N D Child After BirthPremature Y N D Failure to Thrive Y N D Alcohol Exposed Y N D Drug Exposed Y N D Positive for Drugs/no Withdrawal Y N D Addicted Child Y N D Minor Correctable Medical Problem Y N D Major Correctable Medical Problem Y N D Non-Correctable Handicap (Mental) Y N D Non-Correctable Handicap (Physical) Y N D Hearing Impairment Y N D Visual Impairment Y N D HIV Positive Y N D Downs Syndrome Y N D Limited/No Info About Family History Y N D E. OpennessOpenness in adoption provides an opportunity for adoptive parents to have a relationship with their child’s birth parents and to gain insight for their child in a special way. It also allows the birth parents assurance that the child is thriving in his/her adoptive home. Most birth parents we serve are seeking open adoptions. Please indicate your interest in the following options for communicating with the birth parents. Pre Birth Visit(s) Y N D Email Exchange (Before and After) Y N D Providing Pictures After Placement Y N D Face to Face Visit (s) After Placement Y N D Letter Exchange After Placement Y N D Full Exchange of Identifying Information Y N D F. Additional Information1. Do you currently have an application on file with another agency? Yes No If yes, with what agencies and what is the status of your application? 2. Have you ever applied to LSS? Yes No If yes, when? 3. Have either of you ever been interviewed for a home study? Yes No If yes, with what agency, when and were you approved or denied? 4. Have you been married in the past? Yes No If yes, please answer the following: Applicant #1: Year of Marriage? Year of Divorce? Applicant #2: Year of Marriage? Year of Divorce? 5. Are you infertile or unable to have biological children? (this includes same-sex couples and/or inadvisability to have biological children from a medical professional) Yes No If yes, please explain the nature of your infertility, any testing or treatment that you have had and what your plans are for future treatment 6. Please list all current and prior (even if resolved) physical and mental health problems/diagnoses for both applicants. 7. Have you ever been arrested? Yes No If yes, which of you, when, for what infraction and what was the disposition? (must include any expunged criminal history) 8. For what reasons are you seeking adoptive placement? 9. Do you have any personal or family experience with adoption? How did you learn about Lutheran Social Services of the South, Inc. dba Upbring Family/Friend Religious Organization Telephone Book Social Service Agency/Group Professional Brochure Internet Support Group Other How did you learn about us? Signature (Applicant #1) Signature (Applicant #2)
