Application

To apply, you may submit the online application below, fax the attached application to (859) 936-9945 or mail the attached application to us. You will immediately be emailed a home study packet and contacted within 24-48 hours by your assigned adoption worker. The application fee may be paid by a personal check or using Paypal.

Pay with PayPal

Pay by Check

Make checks payable to:
Adoption Assistance
Mail to:
PO Box 2210, Danville, KY 40422

Application

Applicant #1 - Last Name *

First *

Middle *

SS# *

Applicant #2 - Last Name *

First *

Middle *

SS# *

Address *

City *

State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip *

County *

How long at above address? *

#1 Cell:

#2 Cell:

Home Phone

#1 Email: *

#2 Email: *

Applicant #1 Information

Date of Birth *

-

Place of Birth *

U.S. Citizen *

Yes

No

Race *

Religion *

Highest Educational Degree Obtained? *

College & Degree Area

Occupation *

Employer *

Work Phone *

Length of Employment *

Annual Income *

Applicant #2 Information

Date of Birth *

-

Place of Birth *

U.S. Citizen *

Yes

No

Race *

Religion *

Highest Educational Degree Obtained? *

College & Degree Area

Occupation *

Employer *

Work Phone *

Length of Employment *

Annual Income *

Background Details

Date and Place of Marriage *

-

Have either of you been previously married? *

Yes

No

If divorced, date of divorce

Full Name/Date of birth/ages of children living in home *

Full Name/Date of birth/Relation of others living in the home *

Any State, other than current state of residence, that an adoptive parent has resided in the last 10 years *

Have you previously adopted a child? *

Yes

No

Agency Used

Have either of you ever been convicted for violation of any law (including expungements) or are you currently under charges for any violation? *

Yes

No

If yes, please explain

Have either of you ever been diagnosed with a mental illness or addiction? *

Yes

No

If yes, please give diagnosis

Have either of you received counseling? *

Yes

No

If yes, please give the reason

Adoption Details

Type of adoption you wish to pursue *

Domestic

International

Independent

Embryo

-

If International, which country?

-

If Independent, attorney's name/number

How did you learn about Adoption Assistance?

- *

The above data is true and complete to the best of my/our knowledge. We are aware that falsification or information and/or misrepresentation of facts will result in rejection of our application.

Applicant #1 *

Date *

Applicant #2 *

Date *

If you are human, leave this field blank.

(By entering your names above you are signing this application)
A $50.00 application fee is due with the completed application form.