CHILDREN WITH AIDS PROJECT
- Family Registration -
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Please type or Print:
Male Applicant: __________________________ Date of Birth: _________ Race: _________
Employed by: _____________________________ Business Phone: ________________________
Female Applicant: ________________________ Date of Birth: _________ Race: _________
Employed by: _____________________________ Business Phone: ________________________
Address: ______________________________________ Home Phone: _______________________
(mailing address)
______________________________________________ County: ___________________________
City: _______________________________ State: _____ County: _________ Zip: _________
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Use the space below to list the information regarding children living at home, if
more space is needed use separate sheet and enclose with your Family Registration.
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Names of Children Sex Race Date of Natural Adopted Foster or
Living at home Birth Other
______________________________I____I____I__________I__________I_________I_________I
______________________________I____I____I__________I__________I_________I_________I
______________________________I____I____I__________I__________I_________I_________I
______________________________I____I____I__________I__________I_________I_________I
______________________________I____I____I__________I__________I_________I_________I
1. Have you ever applied to an Adoption Agency? Yes (when) ____________ No ________
A. Is your Home Study completed and approved? Date that you completed: _________
B. Is your Home Study nearing completion? Date you began Home Study: _________
If you have answered A or B above, Please complete the following information:
Who is your case worker: _________________________ Contact Phone ( )__________
Agency: __________________________________________ Phone Number ( )__________
Street Address: _______________________________________ Suite Number: __________
City: _______________________________________ State_____________ Zip: __________
2. Would you consider a: Boy___ Girl___ Either___ Age range preference: ___________
3. Your preference regarding racial or national origin: ___________________________
4. Which of the following handicaps in a Child do ___Cerebral Palsy:(___mild, ___moderate, ___severe) ___Missing Limb(s)
___Slow Achiever ____Siblings (number____ age range_______) ___Hyperactive
___Emotionally Disturbed (___mild, ___moderate, ___severe) ___Autistic
___Retarded Child(___mild, ___moderate, ___severe) ___Learning Disabilities
OTHER________________________________________________________________________
5. OPTIONAL: Please write a brief statement about your family. (you can include you
special interests, work experiences, your home and neighborhood, etc. Be sure
to note skill, knowledge or experience with "Special Needs" children and working
with disabilities. Use the back of this form if additional space is needed.)
CONSENT for the Children With AIDS Project of America to make referrals:
I (we) consent to the CWA Project in making referrals to adoption agencies on my
(our) behalf. I (we) understand that these referrals may include, but not be
limited to the CWA Project of America giving my (our) name and information about
my (our) family to adoption agencies and exchanges.
_____________________________ ________ ___________________________ _________
Signature of Female Applicant Date Signature of Male Applicant Date
Children With AIDS Project of America
P.O. Box 23778
Tempe AZ 85285-3778
(480) 774-9718
FAX (480) 921-0449
E-Mail: Jim Jenkins
email webmaster for comments/questions
last updated
June 05, 2009
