RAINBOW HOUSE INTERNATIONAL

Preliminary Application

FAMILY SURNAME:
Your Street Address:

City: State Zip
Husband / Single Applicant Wife
FULL NAME
DATE of BIRTH // //
WEIGHT lbs lbs
HEIGHT inches inches
PHONE FAX#()()
WORK PHONE()()
EMail address
Employment
[Where?]
Salary USD USD
How Long? Years Years
Previous marriage #
Date of Marriage:
Total number of children Biological Adopted
Children's Ages: Sex(es) of Children
Number of foreign born children Country(ies) of Origin
Have you had a previous homestudy completed? NOYes
If yes, what was the date of the study?
Name and Address of the agency completing study:
Have you ever been disapproved for the adoptive placement of a child? Yes NO
Has a child ever been removed from your home? Yes NO
Which parent will be the primary caretaker of the child?
Will one parent be able to take leave when the child(ren) arrive? Yes No
How many infants (by birth or adoption) have you had in your family?
Have you or your spouse ever received counseling or psychiatric care services?
Yes NO
If yes, type received.
Note: Families with no children are asked not to specify the sex of a child. Families with a child or children of one sex may specify the opposite sex.
We are interested in adopting: Male Female Either
Age Range: Siblings
From which Country(ies)

Racial Background
Acceptable Handicaps: Please check those you are open to.
Others:
Blind
Congenital Heart Defect
Eye Conditions
Seizure Disorders
Blood Disorders
Deaf
Missing Limb
Severe Malnutrition
Braces
Delayed Development
Partial Deafness
Tuberculosis
Burns
Delayed physical development
Partial Blindness
Orthopedic Problems
(such as Hemiplegia,Short Limb, Partial Mobility)
Cerebral Palsy
Polio Damage
Cleft Lip and/or Cleft Palate
Diabetes
Positive VDRL
Epilepsy
Rickets
Clubbed Feet
None of the above
Do you have an application on file with another agency? Yes NO
If yes, name and address of agency

If you are sent a formal application we require that you withdraw from all other agencies.
Are you willing to comply with this requirement? Yes NO
The skin color of many foreign born children varies greatly; some are very light and some are very dark. Would the color of a baby be a point for you to consider before adopting? YES NO

Do you feel particularly able to parent a child with a specific problem (i.e. emotional disorder, speech defect, delayed development, or any of the listed handicaps)? If so, please briefly define the nature of the problem that you feel able to handle and why you feel this way:
Have either of you ever been arrested? Yes NO
If yes, please explain:
Briefly, why do you wish to adopt?
Are you in contact with an adoptive parent group in your area? Yes NO
Insurance coverage is very important in the adoption of a child. Have you checked with your insurance agent to ascertain if the child will be covered upon arrival, and if pre-existing conditions will be covered? Yes NO
We have read the information in this packet, and wish to proceed to obtain a Formal Application, or to be placed on the waiting list, or to be referred to an agency which could more readily assist us: WE UNDERSTAND THAT THIS DOES NOT GUARANTEE PLACEMENT OF A CHILD OR THE EXTENSION OF A FORMAL APPLICATION.


_____________________________________ ______________________________________
Single Applicant / Husband's signature & DateWife's signature & Date
(Both signatures are necessary)
PLEASE PRINT AND RETURN THIS PRELIMINARY APPLICATION WITH THE $250.00 PRELIMINARY APPLICATION FEE TO:

Rainbow House International

P.O. Box 53337

Albuquerque, New Mexico, 87153-3337

Jan 2008