Adoption Home Studies by
 Loving Families, Inc.

Please complete the application below and fax to 703-997-2577
or you may mail it to:
Adoption Home Studies by Loving Families, Inc.
12106 Mountain Rd., Lovettsville, VA 20180
There is no application fee.

Name of Adoptive Mother:_______________________________
Date and Place of Birth:_________________________________
Work Phone:__________________________________________

Name of Adoptive Father:_______________________________
Date and Place of Birth:_________________________________
Work Phone:__________________________________________

Home Address:________________________________________
Home Phone;_______________Cell Phone:_________________
E-mail Address:________________________________________

Date and Place of Marriage:______________________________
Prior Marriages:_______________________________________
Others in Home:_______________________________________

Mother's Education:____________________________________
Father's Education:_____________________________________

Have you applied to another agency?___Which one?_________
Have you ever been turned down by another agency or country?______
Have you been named as a defendant in a criminal matter?____
Have you ever been accused of child abuse or neglect?____
Have you ever been a plaintiff or defendant in a civil suit?___
Have you ever had a problem, either as a victim or perpetrator with child abuse, domestic violence, mental illness, sexual abuse, drug and/or alcohol abuse?____
Please explain on another page if any answer is "yes"

Why do you believe that you are qualified to adopt a child?
What kind of direct experiences have you had with children?
Please use an additional page to provide this information.

Name of Placing Agency:________________________________
Desired age, race and sex of child:________________________

3 References with names and addresses:



________________________________________        ______________________________________
      Patent Signature                                                 Parent Signature