Kids to Love Request for Information on Foster and Adoptive Parenting

I would like information for: Foster Care Adoptive Care Foster and Adoptive Care

First Parent Information:

*First Name: *Last Name:

Select an Age Range: Select 18 - 24 25 - 34 35 - 44 45 - 54 55+

Race: Select Asian Caucasian/White Hispanic/Latino Native American/Alaskan Native Pacific Islander/Native Hawaiian African American/Black

Second Parent Information:

First Name: Last Name:

Select an Age Range: Select 18 - 24 25 - 34 35 - 44 45 - 54 55+

Race: Select Asian Caucasian/White Hispanic/Latino Native American/Alaskan Native Pacific Islander/Native Hawaiian African American/Black

*Home Address:

HomeAddress2

*City: *State:

*Zip Code:

If living or stationed outside the U.S. list where:

*Preferred Phone (including area code): Ext:

Alternate Phone (including area code): Ext:

Email Address:

* Best Time to be Contacted: Select 9 - 5 Morning Evening Weekend

*Primary Lanquage Spoken in Home:

Secondary Language Spoken in Home:

Alternate forms of Communication used in the home: Select Braille Sign Language

Have you ever been a Foster/Adoptive Parent before: Yes No

Where did you hear about Foster & Adoptive Parent needs and Kids to Love? TV Internet Search Newspaper/Magazine Church Event/Women's Conference Friend

If you are interested in a child you saw profiled on a Kids to Love news segment please list their name:

*Required