Mother
Father
DETAILS ABOUT THE CHILD'S PARENTS
Surname:
other names:
date of birth:
place of birth:
marital status:
date of marriage:
* PLEASE ATTACH THE PARENTS' AGREEMENT TO ADOPTION OF THE CHILD (THIS
SHOULD BE SIGNED AND ATTESTED) OR EXPLAIN WHY AGREEMENT IS NOT AVAILABLE (eg child orphaned) IF DEAD ATTACH A CERTIFIED COPY OF DEATH CERTIFICATE. PLEASE ATTACH COMPLETED MEDICAL FORM ON EACH PARENT (see note on medical forms)
*
DETAILS ABOUT YOU
Prospective adoptive mother:
Prospective adoptive father:
Surname:
other names:
date of birth:
relationship to child:
Your home address:
B Yes B
No No
Have you ever previously applied to adopt or foster a child? Have you recently had a home study report prepared? If you have answered yes to either of these questions, give name of local authority or agency or individual concerned: (Continue on a separate sheet if necessary).
Please give the names and addresses of two personal referees who know you both well:
1.
2.
Please state how the child came to be offered to you for adoption?
Have you any other children Yes No
If yes please give names and date of birth
I certify that this information is true and correct to the best of my knowledge.
Please sign your names here:
# PLEASE CHECK THAT YOU HAVE ATTACHED ALL THE DOCUMENTS REQUESTED
Note on attestation: A document may be attested (ie witnessed) outside the United Kingdom by a person authorised by a law in the place where the document is signed to administer an oath for a judicial or legal purpose, a British Consular Office, or a Notary Public
+
Page 60Page 61