Foster Child Adoption in North Carolina

July 19, 2008

If you would like more information about children featured on this site or becoming an adoptive parent, please take a few minutes to fill out the following information form. Your interest will be shared with a representative from NC Kids Adoption and Foster Care Network who will contact you.

Information About You

If you have previously contacted NC Kids and/or completed this interest form, please click here.

How did you find our website?

First Name:

Middle Initial:

Last Name:

Spouse’s First Name:

Spouse’s Middle Initial:

Spouse’s Last Name:

Mailing Address:

City:

County:

State:

Zip Code

Home Telephone Number:

Work Telephone Number:

Cell/Mobile Telephone Number:

Best Time To Call:

E-Mail Address:

Do you currently have children in your home?
Yes No

If yes, please provide the following information below.

Birthday	Gender	Adoptive/Foster/Birth
	Male Female	Adoptive Foster Birth
	Male Female	Adoptive Foster Birth
	Male Female	Adoptive Foster Birth
	Male Female	Adoptive Foster Birth
	Male Female	Adoptive Foster Birth

Do you have an approved pre-placement assessment (home study)?
Yes No In study now

Name of agency that completed your pre-placement assessment (home study):

Name of your social worker:

Address of your social worker:

City of your social worker:

State of your social worker:

Zipcode of your social worker:

Your social worker’s telephone number:

Your social worker’s fax number:

Your social worker’s email address:

Date of pre-placement assessment:

Are you licensed for foster care?
Yes No Have applied for license

most recent date of foster care license
are you willing to accept legal risk children?
Yes No

Information About Your Interest

The following information will be used in the future to identify potential matches with other North Carolina children as they become legally free. Please indicate your overall preferences, which may or may not be exactly the same as the child you have recently seen on the website.

I am interested in:
Adoption Foster/Adopt Info.

Number of children desired:
1 2 3 4 5 or more

Gender preference:
Male Female Either

Age preference:

Minimum Age:

Maximum Age:

Ethnicity (race) preference:
White, no Hispanic Origin
White, Hispanic Origin
White/Black (non Hispanic or Latino)
White/Black (Hispanic or Latino)
Black, no Hispanic Origin
Black, Hispanic Origin
American Indian/Alaskan Native, no Hispanic Origin
American Indian/Alaskan Native, Hispanic Origin
Asian Pacific Islander, Hispanic Origin
Any Ethnicity (race)
Other Specify:

Physical Disability Level:
(Select the highest acceptable level)
None Mild Moderate Severe

Emotional Disability Level:
(Select the highest acceptable level)
None Mild Moderate Severe

Learning Disability Level:
(Select the highest acceptable level)
None Mild Moderate Severe

Mental Retardation Level:
(Select the highest acceptable level)
None Mild Moderate Severe

Are you interested in a specific child or sibling group?
Yes No

Name(s) of child or siblings in whom you are interested:

ID # Number of child or siblings:

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