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   INQUIRY FORM

Date:
How did you hear about us?
Name of the child/children that you are inquiring about:
Child's ID#:
Your Name (first and last):
Your Spouse/Partner's name:
Mailing address:
City:
State:
County:
Zip code:
Country:
Email Address:
Daytime phone:
Do you have a completed home study? Yes
No
If yes, what agency completed your home study?
What is the minimum age for a child that you are interested in?
What is the maximum age for a child that you are interested in?
Are you interested in sibling groups?
Are you interested in a male or female?
What race are you interested in? Any
African-American
Caucasian
Hispanic
Native-American
Bi-racial

What level of learning disability are you willing to accept? None
Mild
Moderate
Severe
What level of emotional/behavioral disability are you willing to accept? None
Mild
Moderate
Severe

What level of physical disability are you willing to accept? None
Mild
Moderate
Severe
Additional comments/questions: