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APPLICATION

Applicant's Name (Surname/First/Middle):
Previous/Other Surname:
Birthdate(dd/mm/yy):
Address (including postal code):
Telephone Number:
If you have lived at this address for less than 10 years, list previous addresses:
1.

2.

3.
Gender:
Male Female
Languages Spoken in Home:
Currently practicing faith?
Yes No
If yes, is religion practiced?
Racial Origin:
Education (What level of education have you reached?)
Occupation:
Place of Employment:
Business Telephone #:
Email Address:
Have you ever received services from Child Welfare?
Yes No
Have you ever applied to adopt before?
Yes No

 

Co-Applicant's Name (Surname/First/Middle):
Previous/Other Surname:
Birthdate(dd/mm/yy):
Address (including postal code):
Telephone Number:
If you have lived at this address for less than 10 years, list previous addresses:
1.

2.

3.
Gender:
Male Female
Languages Spoken in Home:
Currently practicing faith?
Yes No
If yes, is religion practiced?
Racial Origin:
Education (What level of education have you reached?)
Occupation:
Place of Employment:
Business Telephone #:
Email Address:

Relationship:
Single, never married
Married
Living common-law
Same-sex couple

 



Divorced
Separated
Widowed
Have you ever received services from Child Welfare?
Yes No
Have you ever applied to adopt before?
Yes No

 

Children in the home:
Name as per
birth registration
Sex
(m/f)
Birth Date
(dd/mm/yy)
Grade
Name of School/
Occupation
1.
2.
3.
4.

 

Other persons currently living with family:
Name Birth Date (dd/mm/yy) Relationship
1.
2.
3.
4.

 

Certification
I/We declare:
1. That the information contained in this application is complete and true to the best of my/our knowledge and that a false statement may disqualify my/our application from further consideration.

2. An acknowledgement that the Children's Aid Society will check internal records for any information relevant to this application and that a criminal record check will also be required. (The existence of a criminal record check will not necessarily result in an exclusion from the program.)