Registration Form

Contact Information:
*First Name:
*Last Name:
Address:
City:
State:	-- None -- AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA OR RI SC SD TN TX UT VT VA WA WV WI WY
Zip:
Country:
*Home Phone:
Work Phone:	ext.
Mobile Phone:
*Email:
Tell us a little about the child you would like to adopt:
How can Adoption ARK help you?	--None-- I am ready to adopt now I might adopt in the future Just doing research Other
Do you have a preferred gender?	--None-- Boy Girl Either Siblings
Do you have a preferred age?	--None-- Under 2 Age 2-5 Older Any
Are you interested in a particular area?	Asia Eastern Europe Latin America
Are you interested in adopting a child with special needs?	--None-- Yes No Maybe
Additional information about the child you would like to adopt:
*Are you currently working with an Adoption ARK coordinator?	None Alla Afinogenova Elina Filippova Kim Fury Ally Griffith Lena Karadjova Dina Latkina Linda Podas Alina Radoslav Tina Venskus Maeven Grish
Please tell us a little background information:
Your Gender:	--None-- Female Male
Birthdate	Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month 1 2 3 4 5 6 7 8 9 10 11 12 Year 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1989 1990 1991 1992 1993
US Citizen Status:	--None-- Yes No
Marital Status:	--None-- Married Single
Number of Marriages:	--None--0 1 2 3 4
How many children do you have at home?	--None--0 1 2 3 4 5 6 7
Annual income (estimate):	$0-20 K $20-50 K $50-80 K Over $80K
Have you completed a homestudy?	No Yes
Do you already have USCIS (formally INS) approval?	No Yes
Do you have a past criminal record?	Yes No Maybe
How did you hear about Adoption ARK?	--None-- Adoption newsgroup Adoption seminar Child listing on another website Client referral Internet search Other agency
Comments & Questions:
Preferred method of contact:
*- Required Fields