"Registration of Adoptive Applicant(S)" - New Brunswick, Canada

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Social Development
REGISTRATION OF ADOPTIVE APPLICANT(S)
(For Office Only)
Date of Initial Contact:
to be initialed by social worker
SECTION A
ADOPTIVE APPLICANT #1
ADOPTIVE APPLICANT #2
SURNAME
GIVEN NAME (S)
MAIDEN NAME
DATE OF BIRTH
PLACE OF BIRTH
LANGUAGES SPOKEN
RACE
RELIGION
HOME ADDRESS
(506)
(506)
TELEPHONE (HOME)
(506)
(506)
TELEPHONE (WORK)
Married
Date of Present Marriage:
MARITAL STATUS
Not Married
Place of Marriage:
MAILING ADDRESS (if different from above)
1
Social Development
REGISTRATION OF ADOPTIVE APPLICANT(S)
(For Office Only)
Date of Initial Contact:
to be initialed by social worker
SECTION A
ADOPTIVE APPLICANT #1
ADOPTIVE APPLICANT #2
SURNAME
GIVEN NAME (S)
MAIDEN NAME
DATE OF BIRTH
PLACE OF BIRTH
LANGUAGES SPOKEN
RACE
RELIGION
HOME ADDRESS
(506)
(506)
TELEPHONE (HOME)
(506)
(506)
TELEPHONE (WORK)
Married
Date of Present Marriage:
MARITAL STATUS
Not Married
Place of Marriage:
MAILING ADDRESS (if different from above)
1
CHILDREN OF PRESENT MARRIAGE OR RELATIONSHIP
GRADE
DATE OF
CHILD'S NAME
IN
ADOPTED/WHERE/WHEN
BIRTH
SCHOOL
OTHER MEMBER(S) OF HOUSEHOLD
NAME
DATE OF BIRTH
RELATIONSHIP
PERSONAL INFORMATION OF APPLICANTS
ADOPTIVE APPLICANT #1
ADOPTIVE APPLICANT #2
Have you ever been convicted of a criminal
Have you ever been convicted of a criminal
offence?
offence?
Yes
No
Yes
No
Or ever been charged with a criminal offence?
Or ever been charged with a criminal offence?
Yes
No
Yes
No
The above shall be verified with the proper authorities. Please note that the possession of a
criminal record will not necessarily prevent the consideration of this application
Has your name ever been registered with
Has your name ever been registered with
Protection Services?
Protection Services?
Yes
No
Yes
No
Have you ever been hospitalized or received
Have you ever been hospitalized or received
treatment for a mental health problem?
treatment for a mental health problem?
Yes
No
Yes
No
Dates:
Dates:
Have you ever received individual/family
Have you ever received individual/family
counseling?
counseling?
Yes
No
Yes
No
Dates:
Dates:
Where:
Where:
Have you ever been involved with another
Have you ever been involved with another
adoption agency or the Department of
adoption agency or the Department of
Social Development with respect to adoption
Social Development with respect to
before?
adoption before?
No
Yes
No
Yes
Please specify nature of involvement:
Please specify nature of involvement:
Note: If you have received any of the above services, you will be required to sign the appropriate
consent for release of information for. A criminal record check is required.
2
SECTION B
PLACEMENT REFERENCE (Please indicate your preference by checking the appropriate boxes)
Could
Could Not
Preferred
Accept
Accept
Age (0 - 2 years)
Over 2 years (state maximum age)
Sex (Male / Female)
Racial/Ethnic Background
• White
• Black
• Native
Siblings (brothers/sisters)
Child who maintains access with a member(s) of the birth family
Special Needs
COULD YOU ACCEPT THE FOLLOWING IN A CHILD'S BACKGROUND?
YES
NO
YES
NO
Cancer
Substance Abuse - Soft Drugs
Tuberculosis
• Marijuana
HIV Positive/AIDS
Hard Drugs
Diabetes
• Cocaine/Crack
Mental Disability
• Heroin
Epilepsy
Alcohol Abuse
Heart Problems
Mental Illness
Limited Information
Schizophrenia
Depression
• Suicide
COULD YOU ACCEPT THE POSSIBILITY THAT A CHILD MIGHT HAVE?
YES
NO
POSSIBLY/COMMENTS
• Diabetes
• Down's
Syndrome
• Hyperactivit y
• Mental
Retardation
Developmental Delays/Slow Learner
• Allergies/Ast hma
• Heart
Problems
• Paraplegia
• Partial
Deafness
• Partial
Blindness
Harelip/Cleft Palate/Club Feet
• Cerebral
Palsy
• Prematurity
• Prematurity
with Complications
Behaviour Problems (stealing, tantrums, aggressive)
Emotional Problems (withdrawn, overactive,
rejecting)
• FAE/FAS
3
YES
NO
POSSIBLY
Child Exposed to abuse situations
• Physical
• Sexual
Neglect (inadequate care/abandoned)
Deprivation (failure to thrive)
Child conceived as a result of:
• Rape
• Incest
• Prostitution
Note:
Many children who are available for adoption today have special needs.
Adoptive parents are especially needed for the following category of
children:
a)
children of all ages who have an emotional/physical/mental/medical handicap
b)
children of the same family being placed together: groups of 2, 3, 4 or more
c)
school age children with or without major problems; or
d)
non Caucasian children to be adopted by Black, native or mixed racial couples.
Adoptive homes are not always readily available for these children, within their respective
areas.
Would you be willing to accept a child/ren with special needs from another region in New
Brunswick?
Yes
No
Contact your adoption worker if you would like to have specific information on an
international adoption.
During the waiting period prior to assessment, prospective adoptive parent (s) are
required to notify the Department of Social Development of any major changes
to their situation (i.e. divorce, death, move, etc)
Signature of Adoptive Applicant #1
Date
Signature of Adoptive Applicant #2
Date
4
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