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Adoption Avenues Application

Please print and mail this application to 

“ADOPTION AVENUES AGENCY” at 

9498 SW Barbur Blvd. Suite 305 

Portland, OR, 97219 

Please attach a personal or bank check of $250.00 (the Application fee)

 

ADOPTION AVENUES AGENCY APPLICATION

Please type or print very clearly, this information will be used to create the legal forms for your dossier

Date__________________

Contact Information

Adoptive father full legal name 

_____________________________________________________________________________

First                                       Middle                                                 Last

Adoptive mother full legal name 

_____________________________________________________________________________

First                                       Middle                                                  Last

Home Address _____________________________________________________________________________

                       Street                   City                       County                State                    Zip

Mailing Address (if different from home address) __________________________________________________________________________________________

                      Street                   City                       County                State                    Zip

Phone Numbers

Home _ (_______) ________________________ Fax __ (_______) __________________________ 

Cell phone __ (________) __________________ Pager __ (_______) _________________________ 

E­mail __________________________________________________ 

Father’s work __ (________) ____________________ Fax __ (_______) _____________________

Mother’s work__ (________) ___________________ Fax ___ (_______) ___________________

Parent Personal Information 

Adoptive Father

Age________ Date of birth _____________________ Place of birth (city, state) ___________________

Social Security Number________________________ 

Driver’s License # _______________________________ 

Citizenship _______________ Passport # _______________________ 

Date of issue _____________________ 

Date of expiration ________________________

Place of issue _____________________________ 

Occupation _______________________________

Yearly income ____________________________

Employer _______________________________________ Phone # _________________________

Employer’s address ___________________________________________________________________________ 

Marital status: 

Single _______ Married, and date ___________  Previously Married (how many times) ____________ 

Education completed __________________________________________________________________________

Adoptive Mother

Age_______ Date of birth ______________________ Place of birth (city, state) ___________________

Social Security Number _________________________ 

Driver’s License # _______________________________ 

Citizenship _________________ Passport # __________________

Date of issue _____________________ 

Date of expiration __________________________ 

Place of issue _______________________________

Occupation _________________________________

Yearly income _____________________________________ 

Employer __________________________________________ Phone # _________________________

Employer’s address ____________________________________________________________________________  Marital status: 

Single_____  Married, and date ______________  Previously Married (how many times) _____________

Education completed ___________________________________________________________________________ 

Children living in your home:                                                         

Full name Birth date Sex (M/F)  Biological?  Adopted? Country and date _______________________________________________________________________________________________________________ 

Full name Birth date Sex (M/F)  Biological?  Adopted? Country and date ____________________________________________________________________________________________________________

Full name Birth date Sex (M/F)  Biological?  Adopted? Country and date ____________________________________________________________________________________________________________

Full name Birth date Sex (M/F)  Biological?  Adopted? Country and date

____________________________________________________________________________________________________________

Other’s living in your home and their relationship with you: ________________________________________________________________________________________________________

Have either of you been arrested or convicted of a crime? _____________________________________________ 

Have any of your children been arrested or convicted? ________________________________________________ 

Do you or anyone in your household, now or in the past, have a problem with alcohol, drugs or gambling?  ____________________________________________________________________________

Do you have any religious or philosophical beliefs that would prevent you from getting medical treatment?  ___________________________________________________________________________

Please list 3 personal references that have known each of you for at least two years

____________________________________________________________________________________________________________

Name Phone number ____________________________________________________________________________________________________________

Name Phone number ____________________________________________________________________________________________________________

Name Phone number

Have you ever been denied approval by a child placement agency?  Yes _______ No_________

 

Paperwork Status

Completed Home Study 

Yes, date completed _______________________ No, estimated date of completion _______________

Home Study Agency:

Name__________________________________________

Address_________________________________________________________________________________________________                   

                    Street                                            City                                       State                             Zip

Social Worker Name _____________________Phone #__________________E-mail _______________________________

Please fax us a copy of your Home Study, if completed, along with a copy of your Home Study Agency’s license and a copy of the completed criminal record check and child abuse check from your Home Study Agency.

INS Approval 

Yes, date approved ______________ # of children approved for __________ 

No, date submitted _________

Adoption Preferences

How many children are you interested in adopting? ________________ 

Are you interested in adopting a sibling group?  Yes ______No______ Possibly _____

Are you interested in adopting two or more unrelated children?  Yes____ No___ Possibly___ 

Please tell us the age and gender of the children you are interested in adopting.

Age___  Male___  Female___  Either___  Siblings___

0­2 yrs___

2­4 yrs___

3­5 yrs___

4­6 yrs___

6­8 yrs___

8 and older___

Please tell us which program you are considering: 

Romania___  Ukraine___  Bulgaria___    Ethiopia___  India____Honduras

Please tell us if you are open to parenting a child with special needs and please check from the list below the disorders you are willing to consider in an adopted child.

Anemia___ Hepatitis A carrier__  Kidney disorder ___

Blindness/ or poor vision___  Hepatitis B carrier___  Missing/malformed ears___

Cleft lip/palate___   Hepatitis C carrier___  Missing/malformed limbs___

Club foot___  Hearing loss/deaf___ Heart defect requiring surgery___

Diabetes___ Hydrocephaly___ Premature birth___ 

Dwarfism___  Heart murmur___ Ptosis (droopy eyelid)___

Rickets___ Birth mother­syphilis ___ Seizure disorder___

Permission to Release Information

I/We give permission to Adoption Avenues Agency to disclose to third parties such information provided by 

Adoptive Parents as Adoption Avenues deems necessary to facilitate the adoption process.

_______________________________________   _____________________________________

Adoptive Mother Date                                     Adoptive Father Date

In order for us to be able to send confidential, guaranteed delivery mailings to you and on your behalf, please set up an account with Fed­Ex (1­800­463­3339) or UPS or DHL.

Your Fed­Ex, UPS or DHL account number _____________________________________________

Adoption Avenues

Adoption Avenues Agency is A 501(c)(3) Not-for-Profit Child Welfare Organization and International Adoption Agency
Licensed by the State of Oregon

Contact us
Adoption Avenues
9498 SW Barbur Blvd. Suite 305
Portland, OR 97219
(503) 977 2870
(503) 977 5095
info@adoptionavenues.org
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Thank you for your interest in Adoption Avenues Agency

If you are looking to adopt you are looking in the right place! Please read our website and then call or email us at:

Adoption Avenues 
9498 SW Barbur Blvd. Suite 305
Portland, OR 97219
(503) 977 2870
(503) 977 5095
info@adoptionavenues.org

We look forward to hearing from you!

The AAA Team!