Prospective Family Inquiry Form

Name:

E-mail address:

Mailing Address:

City: State Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code:

Phone: Work Phone: Mobile Phone:

Age of Child Desired (Check as many as apply):

Newborn
Infant to 1 year
1 to 3 years
3 to 5 years
Over 5 years

ETHNICITY (Check as many as apply)

Full African American
Caucasian/African American
Full Asian
Caucasian/Asian
Full Caucasian (Anglo)
Full Hispanic (Latino)
Caucasian/Hispanic
Full Native American Indian
Caucasian/Native American Indian
Hispanic/Native American Indian

Would you consider adopting a Special Needs Child?: Yes No

How did you learn about A Step Ahead?

Newspaper Radio TV Internet/Website Workshop Flyer Friend Adoption Support Group

I have some specific needs or comments:

*All information collected from this application is secure under our e-mail security*

This message will be sent to

Domestic Inquiry Form (PDF)

International Inquiry Form (PDF)