Infant Adoption Program
Expression of Interest to Attend Group Education Sessions
Please return this form to DHS and attach copies of Birth, Marriage, Decree Nisi & Citizenship )if relevant) Certificates, OR Proof of Length of Relationship. The information, which you provide to DHS/CRE, is used to establish your eligibility to continue with the Infant Adoption Program.
Surname: (Male) (Female)
Given Names: (Male) (Female)
Date of Birth: (Male) (Female)
Occupation: (Male) (Female)
Nationality: (Male) (Female)
Ethnicity: (Male) (Female)
Religion: (Male) (Female)
Date/Place/Marriage:
or Date of Commencement of De Facto Relationship (Proof of Length of Relationship: See Appendix 1)
Address:
Postcode:
E-Mail:
Telephone:
Have you had any biological children? Yes/No (Male) Yes/No (Female)
Please list the names and dates of birth of any children living with you - including natural born, adopted, fostered or from a previous marriage/relationship.
Have you any children not living with you from this/or a previous marriage/relationship? Yes/No (Male) Yes/No (Female)
If "Yes" please list their name/s, dates of birth, with whom and where they reside.
Have you been previously married? Yes/No (Male) Yes/No (Female)
If "Yes" please include copy of Decree/s Nisi with this form.
Have you been seperated during the previous teo years? If "Yes" please specify (a) how often and (b) for what length of time.
Health/Medical:
Detail any past or present, minor or serious illnesses/other conditions relevant to the physical or emotional health of your immediate and extended family members.
Do you consider that there are any aspects of your health (physical, emotional or psychiatric), which currently (or in the future) could affect your ability to raise a child to independence (at least until the child reaches the age of 18) or affect your ability to be fully involved as an active parent. Yes/No.
If "Yes" please complete the attached Appendix 2 (Medical Authority Form) in order that we may follow this up with further specialist opinion. Please specify any such conditions.
Infertility Issues: Please note the following program requirement.
* That couples have fully explored their infertility prior to entering the program.
* That all active fertility treatments must be completed at least SIX MONTHS prior to attendance in the Infant Adoption Education Group Sessions.
Are you able to have biological children? Yes/No
If "No" have you sought medical opinion or assistance? Yes/No
Please outline the reasons for the above.
What explanation/infertility treatment have you received? Please outline in detail, where these treatments took place and the dates of all treatments including the date of the last treatment.
Employment: Are you currently employed, with whom and how long?
Male:
Female:
It is a REQUIREMENT that when a child is placed within an adoptive family ONE parent must remain at home full time for at least the first twelve months. This is to enable the child to settle and to bond with his/her family. Would one of you be in the position to meet this requirement if a child is placed with you? Please provide details.
Have you previously applied to adopt, foster or permanently care for a child/children? Yes/No. If "Yes", please sign and complete Appendix 3.
When:
Details of Program and Agency Name:
What is the current Status of your Application? (Please tick box)
- Waiting to Commence
- Assessment in Progress
- Approved and Waiting
- Deferred
- Not Approved
Babies placed by the Infant Adoption Program are generally healthy, howeverm at times there are babies relinquished who may have difficult or hereditary issues in their background.
Please circle "Yes" if you consider that you could manage any of the conditions below:
Babies born prematurely: Yes/No
Babies who have suffered abuse: Yes/No
Babies who have unknown or uncertain potential: Yes/No
Babies from different social backgrounds: Yes/No
Babies from different racial/cultural heritage: Yes/No
Please give a short explanation of why you consider that you would like to be included in the Infant Adoption Program.
The Adoption Act (1984) recognises the needs of birth families and children for continuing contact during the childs life.
Do you accept this as part of a child's life? Yes/No
Do you understand the implications for you and your family? Yes/No
What issues do your forsee for yourselves, the child and the birth family?
How often do you think you could facilitate contact with the birth family?
Adoption is a lifelong process affecting all parties throughout the life of the adopted person. Even though the adoptive parents become the child's parents by law, the continuing connection between the birth parents and the adoptee should not be under-estimated or under-valued. For instance, have you thought of the birth family's wish to be notified of any serious life threatening illness, or death of the adopted child? Do you wish to comment?
Signed:
Date:
Please note that whilst a couple may be deemed eligible to adopt a child, decisions regarding their suitability are made as part of the formal assessment process, which follows completion of the Education Groups.
Privacy Statement for Adoption Applications
Agency Release of Information Consent Form
Attached: Certificate of Marriage, Birth Certificates
