Application Form
American Russian Connection, Inc.
Application
*Please type or print neatly to complete this form. Then, mail it to ARC, 4531 Connor Drive, Ypsilanti, MI 48197. Be sure to include your non-refundable application fee of $200.00, made payable to American Russian Connection, Inc. As soon as we receive and review your application, you will be contacted by an ARC representative to arrange for a social worker to conduct your home study and/or begin looking for your new family member(s). We ask that you take the medical pages and financial page to a notary public before you mail it to us, as these will be included in your dossier that we send to Russia. Russia requires the medical format that is in this application for your dossier. Russia and INS require the financial form that is in this application for your dossier. If you have any questions about the application, please contact us at 734-528-2394 or KRASUTA@prodigy.net
Contact & Personal Information
Adoptive Mother’s Full Legal Name:
| Place of Birth: | Date of Birth: | # of Siblings: |
| Social Security #: | Passport #: | Occupation: |
| Education Level: | Type of Degree(s): | |
| Religion, and please describe: |
Adoptive Father’s Full Legal Name:
| Place of Birth: | Date of Birth: | # of Siblings: |
| Social Security #: | Passport #: | Occupation: |
| Education Level: | Type of Degree(s): | |
| Religion, and please describe: |
Have either of you ever been arrested for or convicted of a crime? Yes or No
If yes, please say who and explain:
Have either of you applied to any other adoption programs? Yes or No
If yes, please indicate who, when, which one(s) and explain why you are now applying for our program:
Have either of you ever been rejected by another adoption program or been subject to an unfavorable home study? Yes or No
If yes, please explain:
Previous Marriages of Adoptive Parents
Have either of you ever been married previously? Yes or No
Number of previous marriages for adoptive mother. ______
Number of previous marriages for adoptive father. _______
Please list your full legal name during each previous marriage, the dates of the marriages, and the city and states of the marriage and divorce bellow.
| Previous Marriage: | ______________________________________ |
| Full Legal Name | |
| ______________________________________ | |
| Date Married/Date Divorced | |
| ______________________________________ | |
| City, State of Marriage/ City, State of Divorce | |
| Previous Marriage: | ______________________________________ |
| Full Legal Name | |
| ______________________________________ | |
| Date Married/Date Divorced | |
| ______________________________________ | |
| City, State of Marriage/ City, State of Divorce |
Family
Please list any children you have.
Name |
Sex |
Birth Date |
Adopted |
1.____________________________________________________________________
2.____________________________________________________________________
3.____________________________________________________________________
4.____________________________________________________________________
You & Russian Adoption
*This section helps us get to know you.
Please explain why you want to adopt a child from Russia?
What resources have you sought out to prepare yourself for becoming a parent and adopting a child from Russia?
Please describe your plans for when you bring your child home. Who will take care of the child during the day and how will you help acclimate them to their new environment?
Child Selection
How many children are you applying to adopt? _______
Do you want these children to be: Siblings Non-related Either Doesn’t Apply
| 1st Child’s Age: | 8 months-3 years 10-11years |
4-6 years Any Age |
7-9 years |
*Please circle a range above, but indicate a more specific age here. ____
| 2nd Child’s Age: | 8 months-3 years 10-11years |
4-6 years Any Age |
7-9 years |
*Please circle a range above, but indicate a more specific age here. ____
| 3rd Child’s Age: | 8 months-3 years 10-11years |
4-6 years Any Age |
7-9 years |
*Please circle a range above, but indicate a more specific age here. ____
1st Child’s Gender: Male Female Either
2nd Child’s Gender: Male Female Either
3rd Child’s Gender: Male Female Either
Will you accept a child with any of the following health issues: Yes or No
If yes, please circle the one(s) you will accept.
Minor and Correctable Permanent Disability Other
Please explain the one(s) you circled:
Will both parents be traveling to Russia? Yes or No
If no, please explain:
References
Please list five people who have known both of you for five years or more. Please try to include one family member of each parent, a close friend of each parent and/or a co-worker, and/or spiritual leader. If you do not regularly attend a religious service, you do not need to include a spiritual leader. These individuals may be contacted by an ARC representative and/or your social worker, once one has been assigned to you.
Name |
Relationship |
Day # & Evening # |
1.____________________________________________________________________
2.____________________________________________________________________
3.____________________________________________________________________
4.____________________________________________________________________
5.____________________________________________________________________
* The next two sections include the medical evaluations for both parents and the financial form. INS has specific financial guidelines that adoptive parents must be able to meet or you will not be given their approval. Russia also has a concern that parents be in good health and financially able to provide for their new family member(s). The following forms will be submitted to INS and Russia at the appropriate time, so by filling them out now you are that much closer to completing your paperwork J
Medical History of Adopting Mother
Medical History of Adopting Father
By signing this application, we confirm that all the information provided in is true and correct. We understand that providing false or misleading information will be considered sufficient reason(s) for immediate disapproval of our application and that we will not be refunded our $200.00 application fee.
| ______________________________________________________ | |
| Adoptive Mother’s Signature | Date |
| ______________________________________________________ | |
| Adoptive Mother’s Signature | Date |
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