Name:

Address:

City:

Zip:

County:

Home Phone:

Work:

Alternative #:

Age (21 or older)

Yes

No

Do you have a spouse/partner?

Name:

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

Any of the above

Native American

Other

Any of the above

How did you hear about Our Children’s Keeper? (Check One & Provide Name)