International Older Child Adoption and Bright Futures Camp Information Sheet - to Print and Mail

Please Note: Whether you’re interested in adopting or hosting, this Information Sheet is an opportunity for you to share information about your family. This information will enable us to determine if one of our programs may meet your needs. Please print this form, complete all information, and mail the completed form with a current family photo to:

     Gladney Center for Adoption
     Attn: Bright Futures Camp
     6300 John Ryan Drive
     Fort Worth, Texas 76132-4122

I.   FAMILY INFORMATION:
Names:	__________________________________________________
Home Street Address:	__________________________________________________
City, State, Zip:	__________________________________________________
Home Phone Number:	__________________________________________________
Email Address:	__________________________________________________

	MALE	FEMALE
Date of Birth:	_________________	_________________
Race/Ethnicity:	_________________	_________________
Citizenship:	_________________	_________________
Weight and Height:	_________________	_________________
Educational Background:	_________________	_________________
Occupation:	_________________	_________________
Employer:	_________________	_________________
Office Phone:	_________________	_________________
Gross Annual Income:	_________________	_________________
Religious Affiliation:	_________________	_________________
Cell Phone:	_________________	_________________
Previous Marriages:
Number of Previous Marriages:	_________________	_________________
Ages of Children by Previous Marriages:	_________________	_________________
Who has custody?	_________________	_________________
Present Marriage:
Month/Day/Year	_________________
(If less than 3 yrs. indicate length      of relationship)	_________________
Ages of Children by Present Marriage:	_________________
Is your Child/ren Adopted or Biological?	_________________

II.    MEDICAL INFORMATION: List all past and present significant medical conditions. Have you had treatment for emotional, psychiatric, or substance abuse problems?  _________     If yes, please explain, including dates. If necessary, attach a separate page. Have you had individual or marriage counseling?  _________     If yes, please explain, including dates. If necessary, attach a separate page.

III. BACKGROUND INFORMATION Have you been convicted of a felony?________ or misdemeanor?________      If yes, you must include a detailed explanation, including dates. If necessary, attach a separate page. (You will also need to obtain a copy of the arrest record, court documents and disposition of the case for INS records.) Have you ever been found guilty of a crime or pled guilty or nolo contendre to a criminal charge, in order to qualify for deferred adjudication? _________      If yes, please include a detailed explaination, including dates. If necessary, attach a separate page. (You will also need to obtain a copy of the arrest record, court documents and disposition of the case for INS records.) Have you ever been arrested? (Even if that arrest did not lead to charges or a conviction.) _____      If yes, please include a detailed explaination, including dates. If necessary, attach a separate page. (You will also need to obtain a copy of the arrest record, court documents and disposition of the case for INS records). Have you ever applied for adoption? ____  With whom?__________________  Approved?_____      If not approved, explain.      If approved, why are you seeking another agency? Are you acquainted with anyone who has adopted? ________      If yes, whom: ______________________  How are you acquainted?__________ IV.    ADOPTION OF AN OLDER CHILD: What is your program preference?    China ___________ Ethiopia __________  Russia ___________ What is your motivation to adopt? ____________________________________________________________________________________ Do you have relationships with anyone who has adopted internationally or a child who was 4 years of age or older? ________ If yes, please explain. ____________________________________________________________________________________ What age range(s) are you open to adopting?      7-9 yrs___  10-12 yrs___  13-19 yrs___ Are you open to a sibling group? _______ If yes, how many children? _______ Are you open to a child with a medical or developmental challenge? ________ If yes, Correctable:  ________  or Non-correctable:_________ For Bright Futures Camp Families: What is your program preference? China ___________  Ethiopia __________   Russia ___________ How did you hear about Bright Futures Camp? _______________________________________________________________________________ Are you acquainted with anyone who has participated in Bright Futures Camp or who has hosted/ adopted an international child 4 years of age or older? _____________ If yes, please explain. _______________________________________________________________________________ Are you willing to host a child or sibling group in your home for 2-3 weeks? _______ If interested in China, are you willing to travel to China and interact with a child or sibling group for 2 weeks? _______ How do you envision the camp experience? What do you think it includes? _______________________________________________________________________________ Is at least one spouse able to be with your hosted child at all times during the entire camp period? _________ Are you able to attend multiple group activities during various times of the day that may necessitate travel during the camp period? _______ What age range(s)are you open to hosting?   7-9 _____   10-12 _____   13-16 _____ Are you open to a sibling group? _____   If yes, how many children? _____ Are you open to a child with a medical or developmental challenge? ________ Correctable ______   Non-correctable _____ Are you interested in adopting your hosted child? _______   If yes, what is your motivation to adopt? ________________________________________________________________________________