Tapestry Home Study and Adoption Application

Application for Home Study/Adoption Services

Personal Information
Name of Applicant*

PrefixFirst NameMiddle NameLast Name
Name of Applicant #2*

PrefixFirst NameMiddle NameLast Name
Please List any maiden names or nicknames that you have used. Applicant #2
Please List and maiden names or nicknames that you have used. Applicant #1
Email of Applicant 1 *
Email of Applicant 2
example@example.com
Phone number of Applicant #1

Area CodePhone Number
Phone number of Applicant #2

Area CodePhone Number
Address of Applicant*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of Birth Applicant #1
Month/day/year
Date of Birth Applicant #2
Month/day/year
Social Security Number Applicant #1
Social Security Number Applicant #2
Is either applicant apart of a Native American tribe or Alaskan village?

YESNO
Has either applicant lived outside of Indiana in the past 5 years? If so, please provide timeline and address(es)

If there are any other persons in the home 17.5 or over, please list full name, date of birth, and Social Security number. This person will be required to be fingerprinted as well as the main applicants
Please list the names of ALL children in the home and their dates of birth. If child is 13 or above, please list Social Security number, as child will need to have a CPS background check done.
Has either applicant ever been arrested and or charged for anything other than a minor traffic violation?
Has either applicant ever been the subject of a CPS investigation in a state other than Indiana OR been rejected for home study or foster care applications?
Please briefly describe your reasons for wanting to adopt?
Has either applicant received counseling, and if so, in what capacity and time frame? Have you ever been under the care of a psychiatrist, in what capacity and time frame?
REFERENCE CONTACT INFORMATION

Please submit 4 references. At least 2 of the references should be persons who are familiar with your family relational style and have spent time in your home. You may not use familial references.
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Name

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
THE FOLLOWING TWO QUESTIONS ARE ONLY FOR THOSE SEEKING ADOPTION SERVICES: Applicant #1: Tell us about when you accepted Christ and how that relationship affects your world view and daily life. Describe your involvement in your current church.
Applicant #2: Tell us about when you accepted Christ and how that relationship affects your world view and daily life. Describe your involvement in your current church.

This application and the non refundable fee of $250 will begin the application process. This is NOT a contract of services. Please acknowledge that payment of application fee does not guarantee a successful home study approval. We will attempt to flag any issues that come up during interviews, background checks and reference checks which could affect the outcome of your home study.

	Agree
The information I have provided is correct to the best of my ability. Willful concealing of information will render application rejection
I acknowledge that application and corresponding fee do not create a contract to create a home study
My application may be rejected for numerous issues including but not limited to psycho social history, character, criminal history and parenting philosophy.
I/we acknowledge that 50% of the home study fee is refundable if canceled prior to the scheduled interview.

Signature Applicant #1

Clear
Signature Applicant #2

Clear
Should be Empty:

Application for Home Study/Adoption Services

REFERENCE CONTACT INFORMATION