Name Gender MaleFemale MaleFemale Home Address Home Contact Your Email Best Time and Place To Call Emergency Contact Date of Birth Place of Birth Nationality Mother Tongue Martial Status MarriedDivorcedSingleSeparatedWidowed Ocupation Name of Company Currenty Working In Designation Salary Years Employed in Current Position Last Degree Completed Religion Are there any other adults living in your home (other than the spouse/partner listed above)? YesNo Are you a parent? YesNo Do you have a criminal record? YesNo Do you have any significant medical condition (s) that may limit your ability to care for a child: YesNo Adoption Experience: What is your direct experience with adoption? (please check all that apply) I am adoptedI am an adoptive parentI have placed a child for adoptionThis is my first adoption experience Do you have relatives that are adopted, have adopted a child or have placed a child for adoption? YesNo Do you have friends who are adopted, have adopted a child or have placed a child for adoption? YesNo Your Feelings About Adoption: What are your concerns about adopting a child? What do you think your child would want to know about his/her birth parents and the circumstances of his/her birth and adoption? Do you and your spouse/partner have any differences of opinion about adopting a child? If yes, please explain: What is the best thing about your relationship with your spouse/partner that will contribute to the healthy rearing of a child? Have you told friends or relatives about your intention to adopt? If yes, please describe their reaction(s) After you adopt, will you be a stay at home/full-time parent? If no, please describe your child care plans: How did you hear about Imkaan? Internet/FacebookWord of mouthPersonal referral from a friend/acquaintance/associate Is there anything else you would like us to know? Agreement I/we have completed this Prospective Parent Intake Form to the best of my/our ability. By submitting this application, I/we affirm that the facts set forth in it are true and complete. I/we understand that if I/we am/are placed with a child, any false statements, omissions, or other misrepresentations made by me/us on this application may result in the immediate rejection of my/our application.