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Expectant/Birthmother Application – Part Two
1
2
3
4
5
6
7
8
9
Full Name
First
Last
Body Type
Petite/Slender
Average Build
Fit/Athletic
Curvy/Full Figured
Eye Color
Hair Color
Hair Type
Thick
Thin
Curly
Wavy
Straight
Skin Complexion
Are you left or right-handed?
Left
Right
Both
What is your highest level of education?
What was/is your least favorite subject in school?
What was/is your favorite subject(s) in school?
Do you have any special interests or hobbies?
What do you like best about yourself?
Do you like to read?
Yes
No
Sometimes
What do you like to read?
Do you like to cook?
Yes
No
Sometimes
What are your favorite foods to cook?
What is your favorite type of music?
Have you ever traveled?
Yes
No
Where have you traveled to?
Do you play an instrument?
Yes
No
What instrument(s) do you play?
What is your favorite holiday?
What is your favorite color?
Do you like animals?
Do you now have, or have you ever had any pets?
Yes
No
What type of pets?
Do you usually hang out with a group of friends or are you the kind of person who has a few close friends?
What are your future job and/or educational plans or goals for yourself?
Is there anything else that you would like your child to know about you?
In the future, it will be important for your child to know why you believed an adoption plan was in his/her best interest. Please tell us why you think adoption is the best choice for your baby?
Who knows about your pregnancy?
Who knows about your adoption plan?
Do you have other children?
Yes
No
Please let us know about each of your other children.
Other Children
Full Name of Child
First
Last
Age
Gender
Who does this child live with?
Hair Color
Eye Color
Height
Weight
Skin Complexion
Race
Did you have any medical problems during this pregnancy or during the birth of this child? If so, please describe.
Please describe this child's personality
e.g. happy, outgoing, quiet, etc.
Add child
Remove child
Marital Status of your parents
Single
Married
Separated
Divorced
Other
Please briefly describe the marital status of your parents.
How old were you when your parents separated or divorced?
Your Mother
Full Name
First
Last
Age
Please enter a number greater than or equal to
0
.
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone Number
Hair Color
Eye Color
Skin Complexion
Height
Weight
Left-handed or Right-handed?
Right-handed
Left-handed
Both
Race
Ethnicity
Body Type
Petite/Slender
Average Build
Fit/Athletic
Curvy/Full Figured
How many brothers does your mother have?
Please enter a number greater than or equal to
0
.
How many sisters does your mother have?
Please enter a number greater than or equal to
0
.
What is her highest level of education?
What type of work does/did your mother do?
Is your mother alive?
Yes
No
Does your mother have any health problems?
Yes
No
Please describe.
Did your mother have any health problems while she was alive?
Yes
No
Please describe.
What was your mother's cause of death?
How old were you when your mother died?
Your Father
Full Name
First
Last
Age
Please enter a number greater than or equal to
0
.
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Phone Number
Hair Color
Eye Color
Skin Complexion
Height
Weight
Left-handed or Right-handed?
Right-handed
Left-handed
Both
Race
Ethnicity
Body Type
Petite/Slender
Average Build
Fit/Athletic
Curvy/Full Figured
How many brothers does your father have?
Please enter a number greater than or equal to
0
.
How many sisters does your father have?
Please enter a number greater than or equal to
0
.
What is his highest level of education?
What type of work does/did your father do?
Is your father alive?
Yes
No
Does your father have any health problems?
Did your father have any health problems while he was alive?
What was the cause of death?
How old were you when your father died?
Your Siblings
Siblings
Full Name
First
Last
Age
Gender
Hair Color
Eye Color
Height
Weight
Skin Complexion
Right-handed or left-handed?
Right
Left
Both
Race
Ethnicity
What is your siblings highest level of education?
What type of work does he/she do?
Does your brother/sister have any children? If yes, please state each child's name, age and gender.
Add sibling
Remove sibling
Siblings
Full Name
First
Last
Age
Gender
Hair Color
Eye Color
Height
Weight
Skin Complexion
Right-handed or left-handed?
Right
Left
Both
Race
Ethnicity
What is your siblings highest level of education?
What type of work does he/she do?
Does your brother/sister have any children? If yes, please state each child's name, age and gender.
Add sibling
Remove sibling
Siblings
Full Name
First
Last
Age
Gender
Hair Color
Eye Color
Height
Weight
Skin Complexion
Right-handed or left-handed?
Right
Left
Both
Race
Ethnicity
What is your siblings highest level of education?
What type of work does he/she do?
Does your brother/sister have any children? If yes, please state each child's name, age and gender.
Add sibling
Remove sibling
Siblings
Full Name
First
Last
Age
Gender
Hair Color
Eye Color
Height
Weight
Skin Complexion
Right-handed or left-handed?
Right
Left
Both
Race
Ethnicity
What is your siblings highest level of education?
What type of work does he/she do?
Does your brother/sister have any children? If yes, please state each child's name, age and gender.
Add sibling
Remove sibling
Siblings
Full Name
First
Last
Age
Gender
Hair Color
Eye Color
Height
Weight
Skin Complexion
Right-handed or left-handed?
Right
Left
Both
Race
Ethnicity
What is your siblings highest level of education?
What type of work does he/she do?
Does your brother/sister have any children? If yes, please state each child's name, age and gender.
Add sibling
Remove sibling
Siblings
Full Name
First
Last
Age
Gender
Hair Color
Eye Color
Height
Weight
Skin Complexion
Right-handed or left-handed?
Right
Left
Both
Race
Ethnicity
What is your siblings highest level of education?
What type of work does he/she do?
Does your brother/sister have any children? If yes, please state each child's name, age and gender.
Add sibling
Remove sibling
Siblings
Full Name
First
Last
Age
Gender
Hair Color
Eye Color
Height
Weight
Skin Complexion
Right-handed or left-handed?
Right
Left
Both
Race
Ethnicity
What is your siblings highest level of education?
What type of work does he/she do?
Does your brother/sister have any children? If yes, please state each child's name, age and gender.
Add sibling
Remove sibling
Siblings
Full Name
First
Last
Age
Gender
Hair Color
Eye Color
Height
Weight
Skin Complexion
Right-handed or left-handed?
Right
Left
Both
Race
Ethnicity
What is your siblings highest level of education?
What type of work does he/she do?
Does your brother/sister have any children? If yes, please state each child's name, age and gender.
Add sibling
Remove sibling
Siblings
Full Name
First
Last
Age
Gender
Hair Color
Eye Color
Height
Weight
Skin Complexion
Right-handed or left-handed?
Right
Left
Both
Race
Ethnicity
What is your siblings highest level of education?
What type of work does he/she do?
Does your brother/sister have any children? If yes, please state each child's name, age and gender.
Add sibling
Remove sibling
Siblings
Full Name
First
Last
Age
Gender
Hair Color
Eye Color
Height
Weight
Skin Complexion
Right-handed or left-handed?
Right
Left
Both
Race
Ethnicity
What is your siblings highest level of education?
What type of work does he/she do?
Does your brother/sister have any children? If yes, please state each child's name, age and gender.
Add sibling
Remove sibling
Siblings
Full Name
First
Last
Age
Gender
Hair Color
Eye Color
Height
Weight
Skin Complexion
Right-handed or left-handed?
Right
Left
Both
Race
Ethnicity
What is your siblings highest level of education?
What type of work does he/she do?
Does your brother/sister have any children? If yes, please state each child's name, age and gender.
Add sibling
Remove sibling
Siblings
Full Name
First
Last
Age
Gender
Hair Color
Eye Color
Height
Weight
Skin Complexion
Right-handed or left-handed?
Right
Left
Both
Race
Ethnicity
What is your siblings highest level of education?
What type of work does he/she do?
Does your brother/sister have any children? If yes, please state each child's name, age and gender.
Add sibling
Remove sibling
Siblings
Full Name
First
Last
Age
Gender
Hair Color
Eye Color
Height
Weight
Skin Complexion
Right-handed or left-handed?
Right
Left
Both
Race
Ethnicity
What is your siblings highest level of education?
What type of work does he/she do?
Does your brother/sister have any children? If yes, please state each child's name, age and gender.
Add sibling
Remove sibling
YOUR MOTHER'S MOTHER:
FULL NAME OF YOUR MOTHER'S MOTHER:
First
Last
Age:
Hair Color:
Eye Color:
Height:
Weight:
Right-handed or Left-handed?
Right-handed
Left-handed
Both
Skin Complexion:
Race:
Ethnicity:
Body Type:
Petite/Slender
Average Build
Fit/Athletic
Curvy/Full Figured
What is her highest level of education?
What type of work does/did your grandmother do?
Is your grandmother alive?
yes
No
Does your grandmother have any health problems?
Did your grandmother have any health problems while she was alive?
What was the cause of death?
How old were you when your grandmother died?
YOUR MOTHER'S FATHER:
FULL NAME OF YOUR MOTHER'S FATHER:
First
Last
Age:
Hair Color:
Eye Color:
Height:
Weight:
Skin Complexion:
Right-handed or Left-handed?
Right-handed
Left-handed
Both
Race:
Ethnicity:
Body Type:
Petite/Slender
Average Build
Fit/Athletic
Curvy/Full Figured
What is his highest level of education?
What type of work does/did your grandfather do?
Is your grandfather alive?
Yes
No
Does your grandfather have any health problems?
Did your grandfather have any health problems while he was alive?
What was the cause of death?
How old were you when your grandfather died?
YOUR FATHER'S MOTHER:
FULL NAME OF YOUR FATHER'S MOTHER:
First
Last
Age:
Hair Color:
Eye Color:
Height:
Weight:
Skin Complexion:
Right-handed or Left-handed?
Right-handed
Left-handed
Both
Race:
Ethnicity:
Body Type:
Petite/Slender
Average Build
Fit/Athletic
Curvy/Full Figured
What is her highest level of education?
What type of work does/did your grandmother do?
Is your grandmother alive?
Yes
No
Does your grandmother have any health problems?
Did your grandmother have any health problems while she was alive?
What was the cause of death?
How old were you when your grandmother died?
YOUR FATHER'S FATHER:
FULL NAME OF YOUR FATHER'S FATHER:
First
Last
Age:
Hair Color:
Eye Color:
Height:
Weight:
Skin Complexion:
Right-handed or Left-handed?
Right-handed
Left-handed
Both
Race:
Ethnicity:
Body Type:
Petite/Slender
Average Build
Fit/Athletic
Curvy/Full Figured
What is his highest level of education?
What type of work does/did your grandfather do?
Is your grandfather alive?
Yes
No
Does your grandfather have any health problems?
Did your grandfather have any health problems while he was alive?
What was the cause of death?
How old were you when your grandfather died?
INFORMATION ON THE FATHER OF YOUR BABY:
Information on the father of the baby.
Unknown
FULL NAME OF EXPECTANT/BIRTH FATHER:
First
Last
SSN
Phone Number
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo
Congo, Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czechia
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syria Arab Republic
Taiwan
Tajikistan
Tanzania, the United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
Email
Birth Date
MM slash DD slash YYYY
Height:
Weight:
Hair Color:
Eye Color:
Skin Tone:
Bone Structure
Right-handed or Left-handed?
Right-handed
Left-handed
Both
Race:
Is the father of your baby (please check one)?
Single
Married
Separated
Divorced
Engaged
In a Relationship
Other
Please specify the marital status of the father of your baby:
What type of work does he do?
What is his highest level of education?
Does the father of your baby have other children?
Yes
No
Please list their names, ages, and sex:
Signature
Date
MM slash DD slash YYYY
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