Foster Kids Available for Adoption Inquiry: Heart Gallery of Lane County

A Family For Every Child
Heart Gallery
541-343-2856
877-343-2856 christy@afamilyforeverychild.org

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CRM Solutions for Nonprofits

Tax I.D. 20-4151057
Christy Obie~Barrett
Executive Director
880 Beltline Road
Springfield, OR 97477
fax 541-343-2866

OUR MISSION:
To find loving, permanent families for every waiting foster child.

Foster/Adoption Inquiry Form

Please fill out this form with whatever information you would like to share at this point.
Inquire about foster kids available for adoption on this form. We will get back to you immediately!

Fill in below to submit on all the children you are interested in.

If you have already registered and would like to just ask a question please email to
christy@afamilyforeverychild.org .

If you have already registered and want to submit on additonal children use
the form over here!

Parent 1 Information:
First Name:               Last Name:
Stay At Home Parent?                       Occupation:

Parent 2 Information: (if applicable)
First Name:                Last Name:
Stay At Home Parent?                       Occupation:

Parent(s) Contact Information:
Email:      (required)
Address:
City:                     County (Oregon Residents Only):
State/Province:
Zip:          (XXXXX)
Phone:
Mobile:
Fax:

Adoption Agency, Adoption Worker and Home Study Information:
Adoption Agency Name:
Adoption Worker First Name:
Adoption Worker Last Name:
Adoption Worker Street:
Adoption Worker City:
Adoption Worker State:
Adoption Worker Zip:
Adoption Worker Phone:
Adoption Worker Email:
Will Agency Do Pre-Adoption Supervision?
Is The Adoption Agency Certified?
Has a Homestudy Been Completed?
What Is The Date The Home Study Was Completed: (mm/dd/yyyy)

What Are You Interested In?
Adoption?:     Foster-To-Adopt?
Are You Willing To Accept Boy(s)?        Are You Willing To Accept Girl(s)?
Are You Open To Adopting Siblings?
How Many Siblings Will You Consider?

What Ages Are You Interested In?
Birth-5:     6-10:     11-14:     15-18:

Are You Willing To Maintain Contact With...
Foster Parents:     Bio Family:

What Race(s) Are You Interested In?
White: Hispanic: African American/Black: Asian/Pacific Island:
American Indian: Alaskan Native: Other:

What Issues Are You Unwilling To Accept?
Physical:     Emotional:     Learning:     Substance Abuse:
HIV Positive:   Behavioral:     Medical:     Development:

Are You Interested In A Specific Child?

Child's Name 1:    Child's Bulletin Number 1: *
Child's Name 2:    Child's Bulletin Number 2: *
Child's Name 3:    Child's Bulletin Number 3: *

*Bulletin number / ID number is required if you have supplied the child's name.

Additional Child Interests:

How Many Parents Are In The Home?
One Parent Household:
Two Parent Household - Male/Female:
Two Parent Household - Male/Male:
Two Parent Household - Female/Female:

What Are The Parents Ethnicity? (check as many as apply)
White: Hispanic: African American/Black: Asian/Pacific Island:
American Indian: Alaskan Native: Other:

How Many Children Are In Your Home?

What Are The Ages Of The Children In Your Home? (Check as many as apply)
Under 5:      6 to 10:      11 to 14:      15 to 18:      Over 18:

What Is The Ethnicity Of The Children In Your Home (check as many as apply)?
White: Hispanic: African American/Black: Asian/Pacific Island:
American Indian: Alaskan Native: Other:

What Training Has The Family Taken?

Please Provide A Short Family Bio:

How Did You Hear About The Us?
Thru A Friend:     Brochure:     Thru The Radio:     Thru The TV:
Thru A Gallery:       Describe The Gallery Location:
Search Engine:        Describe The Search Engine:
Thru A Website:     Describe The Website:

How Would You Like To Be Contacted?
Would Like Email Newsletters:
Would Like Family Matters:
Would Like Urgent Email Alerts: