Birthfather Application – Part 1

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EXPECTANT FATHER INFORMATION:
Name
First Middle Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth
MM slash DD slash YYYY

Age
Please enter a number from 1 to 120.
Social Security Number
Your place of birth
City State / Province / Region Country

Cell Phone
Ok to text?

Yes

No
Ok to leave VM?

Yes

No
Email

Height
Weight
Skin complexion (e.g. fair, dark, olive, medium)
Race
Marital Status

Single

Married

Separated

Divorced

In a Relationship
Do you have a valid ID?

Yes

No
PLEASE UPLOAD A PHOTO OF ID CARD

Drop files here or

Accepted file types: jpg, gif, png, jpeg, pdf, Max. file size: 512 MB.

Do you have Native American heritage?

Yes

No
Do you have Tribal Enrollment?

Yes

No
What is the name of the Tribe?
Have you ever placed another child for adoption?

Yes

No
Body Type

Slender

Average Build

Fit / Athletic

Heavy Set
Hair Color
Eye Color
Hair Type (Check all that apply)
Thick
Thin
Curly
Wavy
Straight
Handedness

Right-handed

Left-handed

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 type of work do you do?
Do you like to read?

Yes

No
If so, what?
Do you like to cook?

Yes

No
What are your favorite foods?
What is your favorite type of music (i.e, rock, rap, country, blues)?
Have you ever traveled?

Yes

No
If yes, where?
Do you play an instrument?

Yes

No
What instrument?
What is your favorite holiday?
What is you favorite color?
Do you like animals?

Yes

No
Do you now have, or have you ever had any pets?

I have now

I had in the past

No
What are your future job and/or education plans or goals for yourself?
What is the first and last name of the expectant/birthmother of this child?
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 you baby:
Consent
THE ABOVE INFORMATION IS CORRECT AND TRUE TO THE BEST OF MY KNOWLEDGE
IF YOU HAVE OTHER CHILDREN:
How many other children do you have?
Full Name of Child 1:
First Middle Last
Age
Gender

Male

Female
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 yes, please describe:
Please describe this child's personality (i.e. happy, outgoing, quiet, etc.):
Full Name of Child 2:
First Middle Last
Age
Gender

Male

Female
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 yes, please describe:
Please describe this child's personality (i.e. happy, outgoing, quiet, etc.):
Full Name of Child 3:
First Middle Last
Age
Gender

Male

Female
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 yes, please describe:
Please describe this child's personality (i.e. happy, outgoing, quiet, etc.):
Full Name of Child 4:
First Middle Last
Age
Gender

Male

Female
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 yes, please describe:
Please describe this child's personality (i.e. happy, outgoing, quiet, etc.):
Full Name of Child 5:
First Middle Last
Age
Gender

Male

Female
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 yes, please describe:
Please describe this child's personality (i.e. happy, outgoing, quiet, etc.):
Full Name of Child 6:
First Middle Last
Age
Gender

Male

Female
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 yes, please describe:
Please describe this child's personality (i.e. happy, outgoing, quiet, etc.):
Full Name of Child 7:
First Middle Last
Age
Gender

Male

Female
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 yes, please describe:
Please describe this child's personality (i.e. happy, outgoing, quiet, etc.):
Full Name of Child 8:
First Middle Last
Age
Gender

Male

Female
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 yes, please describe:
Please describe this child's personality (i.e. happy, outgoing, quiet, etc.):
Full Name of Child 9:
First Middle Last
Age
Gender

Male

Female
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 yes, please describe:
Please describe this child's personality (i.e. happy, outgoing, quiet, etc.):
Full Name of Child 10:
First Middle Last
Age
Gender

Male

Female
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 yes, please describe:
Please describe this child's personality (i.e. happy, outgoing, quiet, etc.):
Full Name of Child 11:
First Middle Last
Age
Gender

Male

Female
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 yes, please describe:
Please describe this child's personality (i.e. happy, outgoing, quiet, etc.):
Full Name of Child 12:
First Middle Last
Age
Gender

Male

Female
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 yes, please describe:
Please describe this child's personality (i.e. happy, outgoing, quiet, etc.):
Full Name of Child 13:
First Middle Last
Age
Gender

Male

Female
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 yes, please describe:
Please describe this child's personality (i.e. happy, outgoing, quiet, etc.):
Full Name of Child 14:
First Middle Last
Age
Gender

Male

Female
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 yes, please describe:
Please describe this child's personality (i.e. happy, outgoing, quiet, etc.):
Full Name of Child 15:
First Middle Last
Age
Gender

Male

Female
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 yes, please describe:
Please describe this child's personality (i.e. happy, outgoing, quiet, etc.):
Full Name of Child 16:
First Middle Last
Age
Gender

Male

Female
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 yes, please describe:
Please describe this child's personality (i.e. happy, outgoing, quiet, etc.):
Full Name of Child 17:
First Middle Last
Age
Gender

Male

Female
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 yes, please describe:
Please describe this child's personality (i.e. happy, outgoing, quiet, etc.):
Full Name of Child 18:
First Middle Last
Age
Gender

Male

Female
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 yes, please describe:
Please describe this child's personality (i.e. happy, outgoing, quiet, etc.):
Full Name of Child 19:
First Middle Last
Age
Gender

Male

Female
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 yes, please describe:
Please describe this child's personality (i.e. happy, outgoing, quiet, etc.):
Full Name of Child 20:
First Middle Last
Age
Gender

Male

Female
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 yes, please describe:
Please describe this child's personality (i.e. happy, outgoing, quiet, etc.):
Consent
THE ABOVE INFORMATION IS CORRECT AND TRUE TO THE BEST OF MY KNOWLEDGE

YOUR PARENTS:
Marital Status of your Parents (please check one):

Single

Married

Separated

Divorced

Other
Other (Please specify)
How old were you when they separated or divorced?
Full Name of your Mother
First Middle Last
Age
Address
Street Address City State / Province / Region Country

Phone Number
Hair Color
Eye Color
Height
Weight
Skin Complexion
Handedness

Right-handed

Left-handed

Both
Race
Ethnicity
Body Type (please check one)

Petite/Slender

Average Build

Fit/Athletic

Curvy/Full Figured
How many brothers does your mother have?
Sisters?
What is her highest level of education
What type of work does/did your mother do?
Is your mother alive?

Yes

No
Does you mother have any health problems?

Yes

No
Please describe:
What was the cause of her death?
How old were you when your mother died?
Full Name of your Father
First Middle Last
Age
Address
Street Address City State / Province / Region Country

Phone Number
Hair Color
Eye Color
Height
Weight
Skin Complexion
Handedness

Right-handed

Left-handed

Both
Race
Ethnicity
Body Type (please check one)

Petite/Slender

Average Build

Fit/Athletic

Curvy/Full Figured
How many brothers does your father have?
Sisters?
What is his highest level of education?
What type of work does/did your father do?
Is your father alive?

Yes

No
Does you father have any health problems?

Yes

No
Please describe:
What was the cause of his death?
How old were you when your father died?
Consent
THE ABOVE INFORMATION IS CORRECT AND TRUE TO THE BEST OF MY KNOWLEDGE

YOUR BROTHERS AND SISTERS:
How many brothers and sisters do you have?
Full Name Sibling 1
First Middle Last
Age
Gender

Male

Female
Hair Color
Eye Color
Height
Weight
Skin Complexion
Handedness

Right-handed

Left-handed

Both
Race
Ethnicity
What is your sibling's highest level of education?
What type of work does he/she do?
Does your brother/sister have any children?

Yes

No
Please state each child's name, age and gender:
Full Name Sibling 2
First Middle Last
Age
Gender

Male

Female
Hair Color
Eye Color
Height
Weight
Skin Complexion
Handedness

Right-handed

Left-handed

Both
Race
Ethnicity
What is your sibling's highest level of education?
What type of work does he/she do?
Does your brother/sister have any children?

Yes

No
Please state each child's name, age and gender:
Full Name Sibling 3
First Middle Last
Age
Gender

Male

Female
Hair Color
Eye Color
Height
Weight
Skin Complexion
Handedness

Right-handed

Left-handed

Both
Race
Ethnicity
What is your sibling's highest level of education?
What type of work does he/she do?
Does your brother/sister have any children?

Yes

No
Please state each child's name, age and gender:
Full Name Sibling 4
First Middle Last
Age
Gender

Male

Female
Hair Color
Eye Color
Height
Weight
Skin Complexion
Handedness

Right-handed

Left-handed

Both
Race
Ethnicity
What is your sibling's highest level of education?
What type of work does he/she do?
Does your brother/sister have any children?

Yes

No
Please state each child's name, age and gender:
Full Name Sibling 5
First Middle Last
Age
Gender

Male

Female
Hair Color
Eye Color
Height
Weight
Skin Complexion
Handedness

Right-handed

Left-handed

Both
Race
Ethnicity
What is your sibling's highest level of education?
What type of work does he/she do?
Does your brother/sister have any children?

Yes

No
Please state each child's name, age and gender:
Full Name Sibling 6
First Middle Last
Age
Gender

Male

Female
Hair Color
Eye Color
Height
Weight
Skin Complexion
Handedness

Right-handed

Left-handed

Both
Race
Ethnicity
What is your sibling's highest level of education?
What type of work does he/she do?
Does your brother/sister have any children?

Yes

No
Please state each child's name, age and gender:
Full Name Sibling 7
First Middle Last
Age
Gender

Male

Female
Hair Color
Eye Color
Height
Weight
Skin Complexion
Handedness

Right-handed

Left-handed

Both
Race
Ethnicity
What is your sibling's highest level of education?
What type of work does he/she do?
Does your brother/sister have any children?

Yes

No
Please state each child's name, age and gender:
Full Name Sibling 8
First Middle Last
Age
Gender

Male

Female
Hair Color
Eye Color
Height
Weight
Skin Complexion
Handedness

Right-handed

Left-handed

Both
Race
Ethnicity
What is your sibling's highest level of education?
What type of work does he/she do?
Does your brother/sister have any children?

Yes

No
Please state each child's name, age and gender:
Full Name Sibling 9
First Middle Last
Age
Gender

Male

Female
Hair Color
Eye Color
Height
Weight
Skin Complexion
Handedness

Right-handed

Left-handed

Both
Race
Ethnicity
What is your sibling's highest level of education?
What type of work does he/she do?
Does your brother/sister have any children?

Yes

No
Please state each child's name, age and gender:
Full Name Sibling 10
First Middle Last
Age
Gender

Male

Female
Hair Color
Eye Color
Height
Weight
Skin Complexion
Handedness

Right-handed

Left-handed

Both
Race
Ethnicity
What is your sibling's highest level of education?
What type of work does he/she do?
Does your brother/sister have any children?

Yes

No
Please state each child's name, age and gender:
Full Name Sibling 11
First Middle Last
Age
Gender

Male

Female
Hair Color
Eye Color
Height
Weight
Skin Complexion
Handedness

Right-handed

Left-handed

Both
Race
Ethnicity
What is your sibling's highest level of education?
What type of work does he/she do?
Does your brother/sister have any children?

Yes

No
Please state each child's name, age and gender:
Full Name Sibling 12
First Middle Last
Age
Gender

Male

Female
Hair Color
Eye Color
Height
Weight
Skin Complexion
Handedness

Right-handed

Left-handed

Both
Race
Ethnicity
What is your sibling's highest level of education?
What type of work does he/she do?
Does your brother/sister have any children?

Yes

No
Please state each child's name, age and gender:
Full Name Sibling 13
First Middle Last
Age
Gender

Male

Female
Hair Color
Eye Color
Height
Weight
Skin Complexion
Handedness

Right-handed

Left-handed

Both
Race
Ethnicity
What is your sibling's highest level of education?
What type of work does he/she do?
Does your brother/sister have any children?

Yes

No
Please state each child's name, age and gender:
Full Name Sibling 14
First Middle Last
Age
Gender

Male

Female
Hair Color
Eye Color
Height
Weight
Skin Complexion
Handedness

Right-handed

Left-handed

Both
Race
Ethnicity
What is your sibling's highest level of education?
What type of work does he/she do?
Does your brother/sister have any children?

Yes

No
Please state each child's name, age and gender:
Full Name Sibling 15
First Middle Last
Age
Gender

Male

Female
Hair Color
Eye Color
Height
Weight
Skin Complexion
Handedness

Right-handed

Left-handed

Both
Race
Ethnicity
What is your sibling's highest level of education?
What type of work does he/she do?
Does your brother/sister have any children?

Yes

No
Please state each child's name, age and gender:
Full Name Sibling 16
First Middle Last
Age
Gender

Male

Female
Hair Color
Eye Color
Height
Weight
Skin Complexion
Handedness

Right-handed

Left-handed

Both
Race
Ethnicity
What is your sibling's highest level of education?
What type of work does he/she do?
Does your brother/sister have any children?

Yes

No
Please state each child's name, age and gender:
Full Name Sibling 17
First Middle Last
Age
Gender

Male

Female
Hair Color
Eye Color
Height
Weight
Skin Complexion
Handedness

Right-handed

Left-handed

Both
Race
Ethnicity
What is your sibling's highest level of education?
What type of work does he/she do?
Does your brother/sister have any children?

Yes

No
Please state each child's name, age and gender:
Full Name Sibling 18
First Middle Last
Age
Gender

Male

Female
Hair Color
Eye Color
Height
Weight
Skin Complexion
Handedness

Right-handed

Left-handed

Both
Race
Ethnicity
What is your sibling's highest level of education?
What type of work does he/she do?
Does your brother/sister have any children?

Yes

No
Please state each child's name, age and gender:
Full Name Sibling 19
First Middle Last
Age
Gender

Male

Female
Hair Color
Eye Color
Height
Weight
Skin Complexion
Handedness

Right-handed

Left-handed

Both
Race
Ethnicity
What is your sibling's highest level of education?
What type of work does he/she do?
Does your brother/sister have any children?

Yes

No
Please state each child's name, age and gender:
Full Name Sibling 20
First Middle Last
Age
Gender

Male

Female
Hair Color
Eye Color
Height
Weight
Skin Complexion
Handedness

Right-handed

Left-handed

Both
Race
Ethnicity
What is your sibling's highest level of education?
What type of work does he/she do?
Does your brother/sister have any children?

Yes

No
Please state each child's name, age and gender:
Consent
THE ABOVE INFORMATION IS CORRECT AND TRUE TO THE BEST OF MY KNOWLEDGE

YOUR GRANDPARENTS:
Full Name of your Mother's Mother:
First Middle Last
Age
Hair Color
Eye Color
Height
Weight
Skin Complexion
Handedness

Right-handed

Left-handed

Both
Race
Ethnicity
Body Type (please check one):

Petite/Slender

Average Build

Fit/Athletic

Curvy/Full Figured
How many brothers does your grandmother have?
Sisters?
What is her highest level of education?
What type of work does/did you grandmother do?
Is your grandmother alive?

Yes

No
Does your grandmother have any health problems?

Yes

No
Please describe:
What was the cause of death?
How old were you when your grandmother died?
Consent
THE ABOVE INFORMATION IS CORRECT AND TRUE TO THE BEST OF MY KNOWLEDGE

Full Name of your Mother's Father:
First Middle Last
Age
Hair Color
Eye Color
Height
Weight
Skin Complexion
Handedness

Right-handed

Left-handed

Both
Race
Ethnicity
Body Type (please check one):

Petite/Slender

Average Build

Fit/Athletic

Curvy/Full Figured
How many brothers does your grandfather have?
Sisters?
What is his highest level of education?
What type of work does/did you grandfather do?
Is your grandfather alive?

Yes

No
Does your grandfather have any health problems?

Yes

No
Please describe:
What was the cause of death?
How old were you when your grandfather died?
Consent
THE ABOVE INFORMATION IS CORRECT AND TRUE TO THE BEST OF MY KNOWLEDGE

Full Name of your Father's Mother:
First Middle Last
Age
Hair Color
Eye Color
Height
Weight
Skin Complexion
Handedness

Right-handed

Left-handed

Both
Race
Ethnicity
Body Type (please check one):

Petite/Slender

Average Build

Fit/Athletic

Curvy/Full Figured
How many brothers does your grandmother have?
Sisters?
What is her highest level of education?
What type of work does/did you grandmother do?
Is your grandmother alive?

Yes

No
Does your grandmother have any health problems?

Yes

No
Please describe:
What was the cause of death?
How old were you when your grandmother died?
Consent
THE ABOVE INFORMATION IS CORRECT AND TRUE TO THE BEST OF MY KNOWLEDGE

Full Name of your Father's Father:
First Middle Last
Age
Hair Color
Eye Color
Height
Weight
Skin Complexion
Handedness

Right-handed

Left-handed

Both
Race
Ethnicity
Body Type (please check one):

Petite/Slender

Average Build

Fit/Athletic

Curvy/Full Figured
How many brothers does your grandfather have?
Sisters?
What is his highest level of education?
What type of work does/did you grandfather do?
Is your grandfather alive?

Yes

No
Does your grandfather have any health problems?

Yes

No
Please describe:
What was the cause of death?
How old were you when your grandfather died?
Consent
THE ABOVE INFORMATION IS CORRECT AND TRUE TO THE BEST OF MY KNOWLEDGE

Native American Heritage
Please check one of the statements below and the sign and date this form

I confirm that I do not have Native American Heritage

I confirm that although I may have Native American Heritage, I do not have any tribal affiliation.

I confirm that I do have Native American Heritage with:
Tribe(Required)
(Tribe)
in
State(Required)
(State)
Signature
My name on this form means I have read the information as written and it is true to the best of my knowledge.
Consent
THE ABOVE INFORMATION IS CORRECT AND TRUE TO THE BEST OF MY KNOWLEDGE
CAPTCHA

Birthfather Application – Part 1

EXPECTANT FATHER INFORMATION:

IF YOU HAVE OTHER CHILDREN:

YOUR PARENTS:

YOUR BROTHERS AND SISTERS:

YOUR GRANDPARENTS:

Native American Heritage