Waiting Children Application

An approved general America World application as well as signed America World agreements are required to be on file in order for your Waiting Children application to be approved.

Part 1: Applicant Information

I/WE CURRENTLY HAVE AN APPLICATION AND INITIAL AGREEMENTS ON

FILE WITH AMERICA WORLD: YES NO

(IF YOUR ANSWER IS NO, PLEASE FILL OUT THE GENERAL AMERICAN WORLD APPLICATION BEFORE PROCEEDING)

NAME OF FAMILY COORDINATOR:

LAST NAME:

FATHER'S FIRST NAME:

AGE:

MOTHER'S FIRST NAME:

AGE:

EMAIL ADDRESS:

ADDITIONAL EMAIL ADDRESS:

PREFERRED CONTACT NUMBER:

MOBILE

WORK

HOME

ALTERNATE CONTACT NUMBER:

MOBILE

WORK

HOME

DOES YOUR HOME STUDY (OR UPDATE) INCLUDE AN APPROVAL FOR A SPECIAL NEEDS ADOPTION? *Please note this does not include "minor correctable special needs."

PLEASE LIST THE BIRTHDAYS OF ALL THE CHILDREN THAT ARE CURRENTLY LIVING IN YOUR HOME:
Birthday:
Birthday:
Birthday:
Birthday:

DATE THAT YOUR LAST CHILD (THROUGH BIRTH OR ADOPTION)

JOINED YOUR FAMILY

PLEASE ENTER THE LENGTH OF YOUR CURRENT MARRIAGE (YEARS / MONTHS)

HOW MANY DIVORCES DOES EACH SPOUSE HAVE?

HUSBAND

WIFE

WHAT IS YOUR FAMILY'S ANNUAL INCOME?
Ethiopia's guidelines require $10,000 of income per family member
plus $10,000 for the child you plan to adopt.

HAVE YOU COMPLETED AN INTERNATIONAL HOME STUDY THAT IS UNDER 12 MONTHS OLD?
YES NO

IF YES, WHICH COUNTRY:

IS AN AMERICA WORLD GENERAL PHYSICAL EXAMINATION FORM AND DOCTOR'S LETTER (IF APPLICABLE) ON FILE WITH AMERICA WORLD? YES NO
* Please note that a completed General Physical Examination form and doctor's letter (if applicable) need to be on file before a family can receive a referral for a waiting child. Please contact Waiting Children Coordinators with any questions.

Part 2: Family Information

DO ANY OF YOUR CURRENT FAMILY MEMBERS HAVE SPECIAL NEEDS?
YES NO

IF SO, PLEASE DESCRIBE

WHAT EXPERIENCE HAVE YOU HAD WITH CHILDREN AND ADULTS WHO HAVE SPECIAL NEEDS?
(NO EXPERIENCE REQUIRED)

WHY ARE YOU INTERESTED IN ADOPTING A CHILD WITH SPECIAL NEEDS AT THIS TIME?

WHAT ARE YOUR PLANS FOR CHILDCARE? (PLEASE INCLUDE ANY PLANS YOU MIGHT HAVE TO TAKE LEAVE FROM WORK WHEN THE CHILD ARRIVES HOME AND DAILY CHILDCARE AFTER YOU RETURN TO WORK)

AS THE PARENT OF A CHLID WITH SPECIAL NEEDS, YOU WILL NEED SUPPORT. PLEASE DESCRIBE THE SUPPORT SYSTEM YOU WILL HAVE AS THE PARENT OF A CHILD WITH SPECIAL NEEDS.

AS THE PARENT OF A CHILD WITH SPECIAL NEEDS, YOU WILL FACE CHALLENGES AND CRISES. WHAT CHALLENGES OR CRISES HAVE YOU EXPERIENCED AS INDIVIDUALS, AS A COUPLE, OR AS A FAMILY THAT HAS PREPARED YOU FOR PARENTING A CHILD WITH SPECIAL NEEDS?

GRIEF AND LOSS ARE A NORMAL PART OF THE ADOPTION PROCESS. HOW HAVE YOU EXPERIENCED GRIEF AND LOSS IN YOUR OWN LIVES? HOW DID YOU COPE WITH IT?

HOW DID YOU FIRST LEARN ABOUT THE WAITING CHILD PROGRAM?

Part 3: Child Information & Medical Conditions Checklist

WHAT RANGE OF CHILD ARE YOU INTERESTED IN ADOPTING? (CHECK ALL THAT APPLY)

0-2 YRS

3-4 YRS

5-6 YRS

7-8 YRS

9-13 YRS

WHAT GENDER OF CHILD ARE YOU INTERESTED IN ADOPTING?

MALE

FEMALE

EITHER

All of the following special needs range from minor to severe, and families are able to evaluate each child on a case by case basis. (Please check all special needs you are willing to accept. If no, please leave blank. If "yes" is checked, your family will be strongly considered for that particular special need. If "maybe" is checked, your family will only be contacted if no other family on the interested Families list checked "yes" for that particular special need.) Before submitting the completed application, families are requested to print a copy for their records.

YES	MAYBE	Cleft lip/palate
YES	MAYBE	Repaired cleft lip/palate
YES	MAYBE	Albinism
YES	MAYBE	Developmental Delay
YES	MAYBE	Cerebral Palsy
YES	MAYBE	Polio
YES	MAYBE	Spina Bifida
YES	MAYBE	Surgery received for Spinal Bifida
YES	MAYBE	Gastrointestinal disorders
YES	MAYBE	Imperforated or fistula of anus
YES	MAYBE	Kidney malfunction/disease
YES	MAYBE	Genital malformation
YES	MAYBE	Partial hearing loss, moderate
YES	MAYBE	Total hearing loss
YES	MAYBE	Congenital heart defect
YES	MAYBE	Repaired heart defect
YES	MAYBE	Hepatitis B carrier
YES	MAYBE	Hepatitis B active
YES	MAYBE	Club feet
YES	MAYBE	Small Status (Dwarfism)
YES	MAYBE	Webbed or extra fingers or toes
YES	MAYBE	Congenital hip dislocation
YES	MAYBE	Partial or missing appendages
YES	MAYBE	Missing Limbs
YES	MAYBE	Paralysis/Parplegia
YES	MAYBE	Microtia (ear deformity)
YES	MAYBE	Artesia (lack of opening, such as ear)
YES	MAYBE	Use of crutches or braces
YES	MAYBE	Orthopedic problems
YES	MAYBE	Seizures
YES	MAYBE	Hemangioma/large birth mark
YES	MAYBE	Crossed eyes
YES	MAYBE	Possible vision problems
YES	MAYBE	Loss of sight in one eye
YES	MAYBE	Blind
YES	MAYBE	Physical deformity of hands
YES	MAYBE	Physical deformity of feet
YES	MAYBE	Hydrocephalus (water on the brain)
YES	MAYBE	Scoliosis
YES	MAYBE	Repaired medical condition
YES	MAYBE	Healthy child age 6 or older

OTHER (PLEASE EXPLAIN ANY SPECIFIC REQUESTS)

I/We understand that if the homestudy is not completed, then America World will mention that your family has expressed an interest in adopting a child with special needs to the References listed on the initial application.

ACCEPT BY INITIALING

I/We agree and understand that a special needs adoption is pending on my/our ability to obtain an approved home study, as well as gaining approval from the CCAA. I/We understand that by signing the Letter of Intent Application, receiving an approved home study, and/or receiving a Pre-Approval does not grant official approval from the CCAA regarding a specific special needs child. Official approval is obtained once the Travel Letter is received as well as the adoption is finalized in Ethiopia.

ACCEPT BY INITIALING

I/We agree to contact my social worker within 1-2 weeks of the special needs application approval, to make them aware that we are completing a special needs application, as well as to discuss the age range, sex, and special needs that we have expressed potential interest in on this application.

ACCEPT BY INITIALING

I/We recognize that by signing this application I/we are not required to adopt a special needs child. Signing this application does not guarantee I/we will receive a referral for a special needs child.

ACCEPT BY INITIALING

MOTHER

FULL LEGAL NAME:

DATE:

FATHER

FULL LEGAL NAME:

DATE:

BEFORE SUBMITTING THE COMPLETED APPLICATION, FAMILIES ARE REQUESTED TO PRINT A COPY FOR THEIR RECORDS.

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