Gladney Super Kids Adventure Program Application

GLADNEY SUPER KIDS ADVENTURE PROGRAM APPLICATION

Gladney's Super Kids Adventure Program is open to families that reside in Florida, Illinois,
Missouri, New Jersey, Pennsylvania, Texas, and Utah. A full home study is required.

Upon successful submission of the application, you will be prompted to submit payment for the application fee of $200; this can be done via credit card or by sending in a check made payable to Gladney Center for Adoption. Please note that the application fee is a non-refundable payment and not a guarantee that you will be accepted into the Super Kids Adventure Program.

Upon receipt and review of the application and fee, you will be contacted. Approved applicants will be provided with an information packet and required documentation.

Please contact Beth Edwards at Beth.Edwards@gladney.org with any questions.

Please note that fields with "*" are required. If the field does not apply, please enter "NA." With the exception being: if you are applying as a single parent, please leave ALL 'Adoptive Parent 2' fields blank.

We may be able to save you time by pre-filling the form with the information that you have previously entered.

Have you previously submitted your information to us?

Yes, Login

No, Begin Form

Marital Information
Marital Status*
If married, Date of Marriage
Location of Marriage
Ap 1: Number of Prior Divorces*
Ap 1: Date of Most Recent Divorce*	*
Ap 2: Number of Prior Divorces*	*
Ap 2: Date of Most Recent Divorce*	*

Religion
Gladney Center for Adoption is committed to providing an environment that is free from discrimination. Gladney Center for Adoption will ensure equal opportunity for all people without regard to race, color, religion, creed, national origin, gender, sexual orientation, age, ancestry, marital status, disability, veteran or draft status. The questions below are intended for the Country in which you are applying to adopt.
Ap 1 Religion (required for Philippines Program)*
Ap 1 Active Church Member (required for Philippines Program)*	YesNo
Ap 1's Amount of Religious Involvement*
Ap 2 Religion (required for Philippines Program)*	*
Ap 2 Active Church Member (required for Philippines Program)*	YesNo*
Ap 2's Amount of Religious Involvement*	*
If Applicants have different religions, what religion would child be reared?*

Previous Home Study
Have you ever had a previous home study process started?*
YesNo
What agency completed your previous home study (if applicable)?*
*
Estimated Date home study process began*	*
Date home study process was completed or terminated*	*
Have you ever been the subjects of an unfavorable home study or been rejected as prospective adoptive parents?*
YesNo
If Yes, please explain*	*

Family Contact Information

Street Address*

Street Address Line 2

City*

State/Region*

Enter Region

Zip Code*

Country*

Show All Countries

Home Email*

Home Phone Number*

()-ext

Enter Int'l Number

Fax Number

()-ext

Enter Int'l Number

Family Shipping Address

Only enter Shipping Address if it is different from the Residence Address.

Shipping Street Address

Shipping Street Address Line 2

Shipping City

Shipping State/Region

Enter Region

Shipping Zip Code

Shipping Country

Show All Countries

Family Photo
If you do not have an electronic photo available, please mail a photo to our office (labeled with your name and contact information). Once uploaded, your photos will not be viewable except by agency staff for security purposes.
Photo Upload #1*
Please upload a Family Picture
Photo Upload #2
Please upload a Passport Style photo for Applicant 1
Photo Upload #3
Please upload a Passport Style photo for Applicant 2
Photo Upload #4
Please Upload a picture of your home
Photo Upload #5
Please upload an additional Family Picture

Password
Please enter a password to use at a later time to access other forms on our website. Please write down and keep this password in a safe place.
Family Login Password*	Password Already Set Change Password
Confirm Password	*
Password must be at least 8 characters with at least one uppercase letter, one lowercase letter, one number, and one special character.

Education

	Ap 1 Education Level*	Ap 2 Education Level*
		*

Academic History

Family Details - Academic History

Prospective Adoptive Parent*	Academic Institution*	Location*	Type of Degree*	Year of Completion*

PAP 1 Military Service/First Responder
Ap 1 Military Service
Ap 1 DD Form 214 Received
Ap 1 First Responder Job
Ap 1 Verified by Employment Letter

PAP 2 Military Service/First Responder
Ap 2 Military Service
Ap 2 DD Form 214 Received
Ap 2 First Responder Job
Ap 2 Verified by Employment Letter

Prospective Adoptive Parent 1 Work

Ap 1 Employer*

If you are employed outside of the home, when did you become employed at your current job?*

Ap 1 Occupation/Title*

Ap 1 Work Street Address*

Ap 1 Work City*

Ap 1 Work State/Region*

Enter Region

Ap 1 Work Zip Code*

Ap 1 Work Phone*

()-ext

Enter Int'l Number

Prospective Adoptive Parent 1 Finances
Ap 1 Annual Income*	$
Ap 1 Other Annual Income
Does Ap 1 have Life Insurance?*	YesNo
Has Ap 1 ever filed bankruptcy?*	YesNo
Please note any form of government assistance Ap 1 has received within the last 5 years
Ap 1 Bankruptcy Details*	*

Prospective Adoptive Parent 2 Work

Ap 2 Employer

If you are employed outside of the home, when did you become employed at your current job?*

Ap 2 Occupation/Title*

Ap 2 Work Street Address*

Ap 2 Work City*

Ap 2 Work State/Region*

Enter Region

Ap 2 Work Zip Code*

Ap 2 Work Phone*

()-ext

Enter Int'l Number

Prospective Adoptive Parent 2 Finances
Ap 2 Annual Income*	$*
Ap 2 Other Annual Income
Does Ap 2 have Life Insurance?*	YesNo*
Has Ap 2 ever filed bankruptcy?*	YesNo*
Please note any form of government assistance Ap 2 has received within the last 5 years
Ap 2 Bankruptcy Details*	*

Family Financial Information
Family Assets*	$
Family Liabilities*	$

If you list any significant medical or mental health issues, please provide a letter from your doctor. This letter should be forwarded to Gladney as soon as possible after submitting your application so we can thoroughly review for program fit. The letter should be on doctor's letterhead, dated, state how long you have been under the doctor's care, what the diagnosis is, what the treatment is, and what the prognosis is. The letter should also conclude with whether or not the doctor believes the particular medical condition will have a negative impact on your ability to parent an adopted child. And should be notarized, if possible.

Prospective Adoptive Parent 1 Health
Ap 1 Health Status*
Ap 1 Height*
Enter in inches (in)
Ap 1 Weight*
Enter in pounds (lbs)
Ap 1's Health Insurance Covers Adopted Child*	YesNo

Prospective Adoptive Parent 2 Health
Ap 2 Health Status*	*
Ap 2 Height*	*
Enter in inches (in)
Ap 2 Weight*	*
Enter in pounds (lbs)
Ap 2's Health Insurance Covers Adopted Child*	YesNo*

Medical Conditions

Have you or any of your family members had any medical conditions?

Family Details - Medical Conditions

Medications

Family Details - Medications

Criminal History
Have either prospective adoptive parent has ever been arrested, charged, or convicted of any crimes, or spent jail time, including but not limited to, shoplifting, fraud, theft, prostitution, solicitation, DUI, DWI, domestic violence, child abuse, assault, or possession of a controlled substance? (Regardless if expunged, record sealed, etc.) If yes, please describe each occurrence in detail below, including dates.
Has Ap 1 ever been arrested for or accused of child abuse?*	YesNo
Has Ap 2 ever been arrested for or accused of child abuse?*	YesNo*
Has Ap 1 ever been arrested, charged or convicted of any crimes?*
YesNo
Has Ap 2 ever been arrested, charged or convicted of any crimes?*
YesNo*
If the answer to any of these questions is Yes, please provide a detailed explanation of each occurrence, including dates.*	*

Arrest/Conviction Record

Family Details - Arrest/Conviction Record

Children and/or Other Adults Living in Home

Enter all persons (living) in home except Prospective Adoptive Father & Mother.

Persons in Family Home

Adult Children Not in Home

Enter all adult children (living) not in home

Adult Children Not in Home

Program Information
Are you pregnant?	YesNo
Are you attempting to become pregnant or attempting to expand your family in any other way?	YesNo

Home Study Agency

PLEASE NOTE:

The home study agency you choose MUST be Hague Accredited

Your home study MUST be completed by an agency employee, and NOT a contract worker

You MUST complete an International Adoption Home Study in order to proceed with this adoption

Gladney must review and approve your home study

If you are outside of Gladney’s home study service zone, and are still in the process of choosing a home study agency that meets the above criteria, please simply list ‘undecided’ in the text fields, and 00 in the number fields. Please contact us if you require guidance on choosing a home study agency that meets the requirements!

Home Study Agency Name*

Home Study Agency Address*

Home Study Agency City*

Home Study Agency State*

Enter Region

Enter your State of Residence if you do not have a Home Study Agency as of yet

Home Study Agency Zip*

Home Study Agency Phone*

()-ext

Enter Int'l Number

Home Study Agency Contact*

Home Study Agency Contact Email Address*

Expected Completion*

* Please answer the questions below thoroughly, as brief/incomplete answers will delay the processing of your application *

Questions for Family
What is your motivation to participate in the Super Kids Adventure program?*
Are you interested in adopting a child or children? Why or why not?*
Have you ever adopted before? If yes, please list country, date, age and any special needs of child.*
Why do you feel like you would be a good fit for a Super Kids Adventure placement?*
Describe your experience with children, particularly your experience with older children or children with special needs?*
What makes your family a good match for a child with special needs?*
What are your parenting strengths?*
What resources are available in your local area?
Does any household member have a history of domestic violence, child abuse, arrest or addiction? EVEN IF IT DID NOT RESULT IN AN ARREST OR CONVICTION?*

Super Kids Adventure Program \| Child Confidentiality Statement
I understand that I am bound by confidentiality in regard to any child's file that I review.*
I agree not to copy, duplicate, print, and/or share the file/photos/videos with anyone except for professionals (such as doctors, therapists, etc) who can evaluate the child and provide guidance on moving forward with participating in the program.*

Completed Application
Once you have completed all fields on this form, please check this box and click submit*

Statement of Understanding
	I/we affirm that by submitting this Super Kids Adventure Program application, the information provided is true and accurate. I/we further understand that Gladney retains the right to accept or refuse any application. I/we further understand that failure to provide accurate information or to withhold information may result in the termination of services at any time. Additionally, I/we understand that approval of this application does not guarantee approval of a home study or participation in the program. The Super Kids Adventure Program application fee is $200 and is non-refundable. The following payment options are available: Pay Online (a link will be provided after the application has been submitted) Mail a check made payable to: Gladney Center for Adoption. Please indicate “Super Kids Adventure Program Application Fee” in the Memo section of your check. Mail to: 1102 Society Drive, Claymont, DE 19703 PLEASE NOTE: Your application cannot be processed until BOTH the online application AND fee are received by Gladney Center for Adoption. A member of our team will then begin reviewing and processing your application. We are honored and excited to walk through this Super Kids Adventure journey with you!

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Phone: 302-475-8977
Fax: 302-529-1976

Address:
Society Office Complex
1102 Society Drive
Claymont, DE 19703

E-mail:
superkids@gladney.org

	Ap 1 or Ap 2	Charge	Misdemeanor or Felony	Year it occurred

	Ap 1 or Ap 2	Charge	Misdemeanor or Felony	Year it occurred

	Ap 1 or Ap 2	Charge	Misdemeanor or Felony	Year it occurred

	Ap 1 or Ap 2	Charge	Misdemeanor or Felony	Year it occurred

	Ap 1 or Ap 2	Charge	Misdemeanor or Felony	Year it occurred

	Prospective Adoptive Parent*	Medication Name*	Reason for Medication*
	*	*	*

	Dismissed/Guilty/Probation/Not Guilty, etc.	Fine/Probation/Jail, etc.

	First Name	Middle Name	Last Name	Birth Date	Relationship to Family	If Adopted Child, Country Adopted From