GGCF HOMESTUDY INTAKE AGREEMENT FORM
Please provide the following information and return to GGCF with homestudy documents. Please Print carefully and
be accurate and truthful. Attach separate sheet or write answers on back of form.
Applicant Name
Address
DOB
Phone
work phone
cell phone
Email address(es)
Citizenship Passport number
Employer name and address
Social Security Number
Occupation Wages
Have you or a household member resided outside of New York State in the past 5 years? If so where?
Date of Marriage (if applicable)
Date(s) of previous marriages (if any) and divorce(s) and children of the marriage.
List names and contact info for grown children and ex-spouses, if any.
List all others in household with DOB. Include relatives, non relatives and minors.
Do you or any others in your household have a history of ( you MUST answer all questions):
Health/disabling conditions?
Psychiatric or psychological conditions including depression?
Arrest ( even if not convicted)
Substance abuse
Being a victim or respondent in an incident of domestic violence or child abuse allegations
Learning or behavioral problems in school
Has (have) applicant(s) chosen a country yet?
Placement agency if known.
Dates of Post placements required for country or agency if known .
Any other matters you wish to disclose or discuss?
Please return this form with $50.00 non-refundable application to Graham’s Gift Children’s Foundation. After review,
you will be sent the remaining forms and educational materials to complete your adoption. If we do not feel you are a
viable candidate you will be notified within 10 days. Social worker fee of $600 is payable directly to your social worker.
($700 for China) and remaining fee of $650 to GGCF is due at the time clearances are submitted. Your fingerprints
will be expunged from NYS records upon completion of your adoption when report of completed adoption is received.
If approved to undergo the home study process, I agree to read and discuss the provided literature entitled “Adoption
Educational Information” describing the inherent risks and parenting issues of International Adoption as well as take
any required courses described in the parent education program. We agree to submit to post placement visits at 6
months and 1 year and to provide all requested documentation. Additional visits will be done as required by your
placement agency or the foreign government. Additionally, GGCF reserves the right to demand additional post
placement services if they are deemed necessary in our professional opinion. Fees for post placement reports are
$150 payable to the Social Worker and $150 payable to GGCF.
I agree to pay all costs and attorney fees associated with any actions necessary to enforce this agreement with respect
to post placement monitoring.
I swear that the above indicated information is true and complete.
Dated:
______________________________________
applicant
GGCF HOMESTUDY INTAKE AGREEMENT FORM FOR C0-APPLICANT
Please provide the following information and return to GGCF with homestudy documents. Please Print carefully and
be accurate and truthful. Attach separate sheet or write answers on back of form.
Co-Applicant Name
Address
DOB
Phone
work phone
cell phone
Email address(es)
Citizenship Passport number
Social Security Number
Employer name and address
Occupation Wages
Have you resided outside of New York State in the past 5 years? If so where?
Date of Marriage (if applicable)
Date(s) of previous marriages (if any) and divorce(s) and children of the marriage.
List names and contact info for grown children and ex-spouses, if any.
List all others in household with DOB. Include relatives, non relatives and minors.
Do you or any others in your household have a history of ( you MUST answer all questions):
Health/disabling conditions?
Psychiatric or psychological conditions including depression?
Arrest ( even if not convicted)
Substance abuse
Being a victim or respondent in an incident of domestic violence or child abuse allegations
Learning or behavioral problems in school
Has (have) applicant(s) chosen a country yet?
Placement agency if known.
Dates of Post placements required for country or agency if known .
Please return this form with $50.00 non-refundable application to Graham’s Gift Children’s Foundation. After review,
you will be sent the remaining forms and educational materials to complete your adoption. If we do not feel you are a
viable candidate you will be notified within 10 days. Social worker fee of $600 is payable directly to your social worker.
($700 for China) and remaining fee of $650 to GGCF is due at the time clearances are submitted. Your fingerprints
will be expunged from NYS records upon completion of your adoption when report of completed adoption is received.
If approved to undergo the home study process, I agree to read and discuss the provided literature entitled “Adoption
Educational Information” describing the inherent risks and parenting issues of International Adoption as well as take
any required courses described in the parent education program. We agree to submit to post placement visits at 6
months and 1 year and to provide all requested documentation. Additional visits will be done as required by your
placement agency or the foreign government. Additionally, GGCF reserves the right to demand additional post
placement services if they are deemed necessary in our professional opinion. Fees for post placement reports are
$150 payable to the Social Worker and $150 payable to GGCF.
I agree to pay all costs and attorney fees associated with any actions necessary to enforce this agreement with respect
to post placement monitoring.
I swear that the above indicated information is true and complete.
Dated:
______________________________________
applicant
 |
 |