Please let us know how we may serve you

Name:
Address:
City:			Zip:
County:			Home Phone:
Work:			Alternative Phone:
Email Address:
Are you 21 years of age or older?         Yes				No
Do you have a spouse/partner?            Yes				No
Name:
Do you have children living in the home? If yes, what are their names and ages?
Boy(s) Name(s)
Boy(s) Age(s)
Girl(s) Name(s)
Girl(s) Age(s)
Does anyone else live in the home?      Yes				No
Gender		Age
How many bedrooms in your home?
Check the age, gender and race of children you prefer. (Check all that apply)
AGE		GENDER		RACE
	0-4		Male		Black/African American
	5-8		Female		Asian
	9-12		Any of the above		Whote/Caucasian
	13-19				Hispanic
	Any of the above				Native American
					Other
					Any of the above
How did you hear about Our Children's Keeper? (Check one and provide name)
		Family/Friend
		Foster Parent	Name
		Community Event
		Publications	Name
		Billboard Advertisement
		Penny Saver
		Internet
		Other
		Please check box if you would like to schedule an orientation