Birthfather Application – Part 1

• Expectant/ Birthfather Applications - Part 1
• Expectant/ Birthfather Applications - Part 2

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  EXPECTANT FATHER INFORMATION:

  Name

  First Middle Last

  Address

  Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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 Select files

  Accepted file types: jpg, gif, png, jpeg, pdf, Max. file size: 16 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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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 AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands 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