Foster/Adoption Family Survey

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Phone

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

Referred By

Date

I/We Desire to

Age Range, Sex, Race of Child Desired*

Applicant 1

First Middle Last

Home Telephone#*

Birth Date

Birth City

State

County

Social Security No.

Race

High School Attended (address and years attended)

Current Address / Mailing Address

Street City State Zip Country

Previous Address

Street City State Zip Country

Applicant 2

First Middle Maiden Last

Birth Date

Birth City

State

County

Social Security No.

Race

High School Attended (address and years attended)

Current Address / Mailing Address

Street City State Zip Country

Previous Address

Street City State Zip Country

Marital Status

If Married

Date

City

State

Date of Divorce

Applicant 1

Applicant 2

Present Employment

Applicant 1

Employer

Address

Telephone No.

Occupation

Number of Years Employed

Education/grade Completed

Wife

Husband

Present Employment

Applicant 2

Employer

Address

Telephone No.

Occupation

Number of Years Employed

Other Family Members in the Home

Name

Relationship

Birth Date

School, Grade or Employer

List the Names of Other Agencies to Which You Have Applied to Adopt or Provide Foster Care

References

Please list five (5) personal references that may be contacted (Must have known for at least five years): Only one relative, please.

Name

Street

City

State

ZIP Code

Phone No.

Name

Street

City

State

ZIP Code

Phone No.

Name

Street

City

State

ZIP Code

Phone No.

Have you been convicted or charged with any criminal offense other than a minor traffic violation?

Yes

Please Explain

Certification

I/We fully certify that, to the best of my/our knowledge and belief, statements given truly represent my background and experience. I understand that failure to give complete and accurate information may prohibit my participation in the Foster/Adoption Program. Misrepresentation at any point in the process may be grounds for termination of Foster/Adoption Services through Another Choice. I/We further understand that completion of this inquiry form does not ensure the placement of a child in my home or the approval of my family as a Foster/Adopt family. I/We fully understand that at the point of application, all references will be checked, as well as criminal records check, fingerprints, social services, mental health, and medical information. All information submitted to ANOTHER CHOICE FOR BLACK CHILDREN, Adoption Agency will be handled in a confidential manner.

Applicant 1’s Signature

Date

Applicant 2’s Signature

Date

ANOTHER CHOICE does not discriminate on the basis of age, race, religion, sex or national origin. The placement of children five and above or those who have brothers and sisters is our focus.

Revised July 2017
Contact Info: Another Choice For Black Children, Inc 3028 Beatties Ford Road Charlotte, NC 28216 (704) 394-1124 Office (704) 394-2645 Fax

I’d like more information on:

Adoption (NC residence only)

Foster Care (NC residence only)

Volunteering

Donations

Another Choice is licensed to provide services for North Carolina residents only