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Online Application: After completing this form application, print and mail to Hopscotch Adoptions, Inc with your application fee attached. 

 

First Name
Nickname P1:
Date of Inquiry:
Last Name
Address
City
State/Province
Zip
Country
Phone
Email
Fax
Marital Status	--None-- Married Single Divorced
Head of Household
Date of Birth Parent 1
Emergency Contact Person
Emergency Phone
All Places lived over 4 months - P1
Spouse First Name
Nickname P2
Spouse's Last Name
Spouse's Work #
Spouse's Cell #
Spouse's Email
Date of Birth Parent 2
All Places lived over 4 months - P2
Starting Time Frame	--None-- Immediately Within 3 to 4 months Within 6 months Within a year Undecided Now
Services Interested In	--None-- Inquiry Only Homestudy Only Placement Only Donation Both - Homestudy & Placement
How Did You Hear about us?	--None-- Adoption.com Adoption Ratings Doctor or medical prof Family member referral Former client referral Former client returning - next adoption Friend Hopscotch website Internet Site Other Rainbow Kids Reeces Rainbow
Homestudy Ready	--None-- No Pending Yes
If yes, Date of Homestudy
Homestudy Agency
Homestudy Consultant
Homestudy Agency Address
Homestudy Consultant Phone #
Homestudy Consultant Email
USICS Ready (171H)	--None-- Yes No
171 Approval Date
171H Expiration Date
171H Expiration Fingerprint Date
Country Change
Country Changed From
Foster Care Information
State & Agency for Foster License
Disrupted/Placement Adopt
Reason for Disruption
Denied a Homestudy	--None-- Yes No
Reason for Homestudy Denial
Maiden Name
Birth Place (City&State) P1
Citizenship (All) P1
Height & Weight P1
Eye & Hair Color P1
Ethnicity (P1)
Date High School Grad P1
College Prof Training P1
College Prof Training Date P1
Hobbies & Community Activities P1
Religious Affiliation P1
Worship Community Name
Occupation P1
Employer P1
Job Title P1
Annual Gross Income P1
Savings
Other Income P1
Arrest Record Parent 1
Arrest Explain Parent 1
Maiden Name P2
Birth Place (City&State) P2
Citizenship (All) P2
Height & Weight P2
Eye & Hair Color P2
Ethnicity (P2)
Date High School Grad P2
College Prof Training P2
College Prof Training Date P2
Hobbies & Community Activities P2
Religious Affiliation P2
Worship Community Name P2
Occupation P2
Employer P2
Job Title P2
Annual Gross Income P2
Savings P2
Other Income P2
Arrest Record Parent 2
Arrest Explain Parent 2
Marriage Date
Location of Marriage
All Divorce Info - Name, Reason, Dates
Child 1 Name at Home
DOB Child 1 in Home
Age Child 1 In Home
Bio/Adopted Child 1	--None-- Bio Adopted
Child 1 at Home Adopt Date
Country Adopted & Agency Child 1
Personality Child 1 in Home
School Child 1 At Home
Child 2 Name at Home
DOB Child 2 in Home
Age Child 2 In Home
Bio/Adopted Child 2	--None-- Bio Adopted
Country Adopted & Agency Child 2
Child 2 at Home Adopt Date
Personality Child 2 in Home
School Child 2 At Home
Child 3 Name at Home
DOB Child 3 in Home
Age Child 3 In Home
Bio/Adopted Child 3	--None-- Bio Adopted
Child 3 at Home Adopt Date
Country Adopted & Agency Child 3
Personality Child 3 In Home
School Child 3 At Home
Child 4 Name in Home
DOB Child 4 in Home
Age of Child 4 in Home
Bio/Adopted Child 4	--None-- Bio Adopted
Country Adopted & Agency Child 4
Child 4 at Home Adopt Date
Personality Child 4 In Home
School Child 4 At Home
Child 5 Name in Home
DOB Child 5 in Home
Age of Child 5 in Home
Bio/Adopted Child 5	--None-- Bio Adopted
Country Adopted & Agency Child 5
Child 5 at Home Adopt Date
Personality Child 5 In Home
School Child 5 At Home
Child 6 Name in Home
DOB Child 6 in Home
Age of Child 6 in Home
Bio/Adopted Child 6	--None-- Bio Adopted
Country Adopted & Agency Child 6
Child 6 at Home Adopt Date
School Child 6 At Home
Personality Child 6 In Home
All Info Child 7+ In Home
All Children Not living In Home
All Places lived over 4 months-kids 18+
Rent or Own	--None-- Rent Own
Lot Size
Home Value - if own
Monthly Payment
Mortgage Balance
Services In Community
Is Your Community Diverse
Medical Lifestyle Parent 1	Alcoholism Anemia Arthritis Blood transfusions Cancer or Tumor Cholesterol Communicable Disease Depression Diabetes Drug Abuse Epilepsy/Seizures Head Injuries Hepatitis High Blood Pressure/ HIV/AIDS Jaundice Kidney Problems Liver Disease Ling Disease/TB Mental Illness Mood Disorder Neurological Disorder Obesity Personality Disorder Physical Impairment Sexually Transmitted Disease Smoking Stroke Suicide Attempt Thyroid Disease Ulcer/Duodenum
Medical Lifestyle Notes Parent 1
Medications Taken P1
Hospitalizations (P1)
Counseling/Psycho Therapy P1
Any Medical Explain P1
Medical Lifestyle Parent 2	Alcoholism Anemia Arthritis Blood transfusions Cancer or Tumor Cholesterol Communicable Disease Depression Diabetes Drug Abuse Epilepsy/Seizures Head Injuries Hepatitis High Blood Pressure/ HIV/AIDS Jaundice Kidney Problems Liver Disease Ling Disease/TB Mental Illness Mood Disorder Neurological Disorder Obesity Personality Disorder Physical Impairment Sexually Transmitted Disease Smoking Stroke Suicide Attempt Thyroid Disease Ulcer/Duodenum
Medical Lifestyle Notes Parent 2
Medications Taken P2
Hospitalizations (P2)
Counseling/Psycho Therapy P2
Any Medical Explain P2
Country Interest	Special Needs Down Syndrome Armenia Bulgaria Georgia Ghana Morocco Undecided
Country Preference
Gender Preference	--None-- No Preference Female Male
Child Age Preference	--None-- Infant Up to 12 months Up to 18 months Up to 24 months 2 to 4 years old 4 to 6 years old 7 years & older
Preferences about Child
Number of Children	--None-- 1 2 Unrelated 2 Siblings 3 4+
Medical Preference	Boy Girl Siblings/Twins 3 months - 12 month (time of referral) 1 to 3 yrs (time of referral) 4-5 yrs (time of referral) 5+ yrs (time of referral) Allergies or asthma Cleft palate/lip = correctable Club foot/feet = correctable Cosmetic issues Crossed eyes = correctable Delayed development Delayed emotional development Extrophy Bladder Fused fingers/toes Genitalia Issues Healthy Hepatitis/Other Blood Disorder Impaired hearing Impaired sight Missing fingers/toes Missing limbs Muscular Distrophy Needs glasses Orthopedic Disorders Other - see comments Seizure Disorder Smaller in size
Medical Would Consider	Boy Girl Siblings/Twins 3 months - 12 month (time of referral) 1 to 3 yrs (time of referral) 4-5 yrs (time of referral) 5+ yrs (time of referral) Allergies or asthma Cleft palate/lip = correctable Club foot/feet = correctable Cosmetic issues Crossed eyes = correctable Delayed development Delayed emotional development Extrophy Bladder Fused fingers/toes Genitalia issues Healthy Hepatitis/Other Blood Disorder Impaired hearing Impaired sight Missing fingers/toes Missing limbs Needs glasses Orthopedic Disorder Other - see comments Seizure Disorder Smaller in size
Medical Least Preferred	Boy Girl Siblings/Twins 3 months - 12 month (time of referral) 1 to 3 yrs (time of referral) 4-5 yrs (time of referral) 5+ yrs (time of referral) Allergies or asthma Cleft palate/lip = correctable Club foot/feet = correctable Cosmetic issues Crossed eyes = correctable Delayed development Delayed emotional development Extrophy Bladder Fused fingers/toes Genitalia issues Healthy Hepatitis/Other Blood Disorder Impaired hearing Impaired sight Missing fingers/toes Missing limbs Needs glasses Orthopedic disorders Other - see comments Seizure Disorder Smaller in size
Other Adult in Home Name 1
Other Adult General Info (1)
Child Abuse Clear 18+ (1)
FBI Clear 18+ (1)
Other Adult in Home Name 2
Other Adult General Info (2)
Child Abuse Clear 18+ (2)
FBI Clear 18+ (2)
Other Adult in Home Name 3
Other Adult General Info (3)
Child Abuse Clear 18+ (3)
FBI Clear 18+ (3)
All Places lived over 4 months - adults