The application below is the first step in the intercountry adoption process. By filling out this application, Bethany will be able to determine whether you are eligible for the country or countries in which you are interested. You must fill in the form completely for Bethany to process your application. Because of the specific requirements of an intercountry adoption, we suggest that you thoroughly review our information packet or the information on Bethany’s website before completing this application. If you would like more information prior to completing this application, you may want to attend one of Bethany’s Intercountry Adoption information meetings offered by your local Bethany office. If you have questions, please email info@bethany.org *denotes required field. Previous Bethany Adoption?* Yes No        Who was your social worker?*   Street address*     City* AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY   State*     County*   Zip*   Home Phone*     Fax Primary e-mail address*   ADOPTIVE FATHER (or Single Parent Applicant)   First*     Middle   Last* Office telephone     Date of birth*     Age* Place of birth* Are you a U.S. Citizen?* Yes   No *USCIS Regulations require at least one U.S. Citizen Date of marriage (if applicable)   ADOPTIVE MOTHER   First*     Middle   Last* Office telephone     Date of birth*     Age* Place of birth* Are you a U.S. Citizen?* Yes   No Place of marriage (if applicable) 0 1 2 3 4   Number of previous marriages *(if applicable) 0 1 2 3 4   Number of previous marriages *(if applicable)   Please list dates of marriage and date of dissolution and reason, i.e., death or divorce.* Religious Preference*   Occupation*   Employer*   Annual earnings*     Height*     Weight* Do you have any physical or mental health conditions?* Yes   No   Please list physical and/or mental health conditions* Please list any prescriptions and their purpose*   Please list dates of marriage and date of dissolution and reason, i.e., death or divorce.* Religious Preference*   Occupation*   Employer*   Annual earnings*     Height*     Weight* Do you have any physical or mental health conditions?* Yes   No   Please list physical and/or mental health conditions* Please list any prescriptions and their purpose*       Emergency contact person   Relationship   Telephone   Has either applicant, or a household member, ever been arrested? *       Yes No Please explain arrest in detail including date of arrest and reason.* Children Name Male Female Gender   Birthdate Yes No   Lives at home   Adopted? (If so, give country of birth.) Name Male Female   Gender   Birthdate Yes No   Lives at home   Adopted? (If so, give country of birth.) Name Male Female   Gender   Birthdate Yes No   Lives at home   Adopted? (If so, give country of birth.) Name Male Female   Gender   Birthdate Yes No   Lives at home   Adopted? (If so, give country of birth.) Name Male Female   Gender   Birthdate Yes No   Lives at home   Adopted? (If so, give country of birth.) (Please list additional children in comments section at end of form.) If you have had previous contact with an adoption agency, please list the following:         Agency Address Telephone Social Worker         Agency Address Telephone Social Worker To which programs are you interested in applying? Bulgaria  China  Colombia  Ethiopia  Haiti  Hong Kong  Lithuania  Philippines  Russia  South Korea  Taiwan  Ukraine  Homestudy Only    Please list the agency and country you are working with* Type of Child Desired Due to the nature of intercountry adoptions, the various countries may/may not allow families to specify what type of child they want. This will be discussed in the family assessment. For our information, please describe the type of child you can parent. Please be as flexible as possible. Would you accept a boy or a girl?* Yes   No    Please explain gender preference* Would you consider siblings?* Yes   No Acceptable age range* Would you accept a child with minor medical problems?* Yes   No Would you consider moderate to severe problems?* Yes   No Can you cover/afford all medical expenses not covered by your insurance?* Yes   No If required, are both of you able to travel abroad?* Yes   No    Please explain travel restrictions* Can one parent take a leave of absence after placement of a child?* Yes   No How did you hear about Bethany?* Choose one... Bethany publication Search engine Billboard Television Newspaper Yellow Pages Presentation Church Other agency Other website Previous adoption Word of mouth Other Additional comments If you have any questions, please contact your local office or call us at 1-800-652-7082 or email bcsinternational@bethany.org.