Brebis de Saint-Michel de L'attalaye Adoption Application
Your Full Name:
Are you Married?:
If you are married please state your spouses full name and Date-of-Birth below, if you are not married please type N/A below
Your Spouses Full Name:
Your Mailing Address:
Your Phone Number:
Your E-mail Address:
Your Date-of-Birth:
Your Spouses Date-of-Birth:
Please describe your Religious Faith:
Have you or your spouse ever been previously married?:
How long have you been Married?:
(if you are not married type N/A)
Do you have any Children:
If You do have children Please list their Names Ages and if they are adopted (if so from where) or biological, if you do not have any children please type N/A:
Describe your employment:
Describe your spouses employment:
(If not married type N/A)
What made you decide on Haiti as the country you would adopt from?:
If you adopt,do you plan on celebrating and keeping alive your child’s Haitian Culture within your family?:
How Many Children are you wishing to adopt?:
How Many Siblings would you consider adopting who must remain together?:
Please select the Gender of child you wish to adopt:
Please indicate an age range for the child(ren) you wish to adopt, listing the youngest child you would consider to the oldest child you would consider:
What Special Needs if any would you be willing to consider?:
The following is a list of special needs found in some Haitian Children, this is not a complete list however:
Sickle Cell Anemia, Sickle Cell Trait, Hep B, Hep C, Congenital Heart Defects, Anemia, Severe Malnutrition, Failure to Thrive, Cerebral Palsy, Developmental Delays, HIV, Downs Syndrome, Low Muscle Tone, Deformations, Attachment Disorders, Mentally Handicapped.
(If you are not willing to accept any form of special needs please type none)
Have you ever adopted a child and then disrupted the adoption?:
If you have disrupted an adoption please explain (if you answered no to the previous question please type N/A in this box):
Please type today's date:
By submitting this form you agree that this is an application for adoption and does not ensure your approval, you also agree that all of the information above is true and correct. If you agree to this statement please click the submit button that best describes your family.
Do you suffer from any form of infertility? If so please explain, if not please type N/A in the box provided:
