Please complete the form below, and additional information will be sent to you
Name:
Address:
City:
Zip:
County:
Home Phone:
Work:
Alternative #:
Age (21 or older)
Yes
No
Do you have a spouse/partner?
Do you have children living in the home? If yes, what are their names and ages.
Boy/s Names
Boy/s Age/s
Girl/s Names
Girl/s Age/s
Does anyone else live in the home?
Number of bedrooms
Check the age, gender and race of children you prefer. (check all that apply)
Age
Gender
Race
0-4
Black/African American
5-8
Asian
9-12
Any of the above
White/Caucasian
13-19
Hispanic
Native American
Other
How did you hear about Our Children’s Keeper? (Check One & Provide Name)
Please check box if you would like to schedule an orientation