Special Needs (ASAP) Adoption - Pre-Application

Spence-Chapin is currently accepting applications from families who are open to adopting a child with significant medical needs. Families are encouraged to complete our free pre-application below to become registered.  Please send us a copy of your current home study (completed within the past 12 months), conducted by a licensed adoption agency. 

Email: asap@spence-chapin.org

Fax: (888)-742-6126

Mail: Special Needs at Spence-Chapin, 410 East 92nd Street, 3rd Floor, New York, N.Y. 10128

General Information Are you applying as a couple or a single applicant?* Couple Single   Applicant 1's General Information Last Name* * First Name* * Middle Name Email Home Phone ()-ext Enter Int'l Number Work Phone* ()-ext Enter Int'l Number Applicant 1's Cell Phone ()-ext Enter Int'l Number Occupation* Gender* Female Male Please Specify *  If "Please Specify", please write gender here: Date of Birth* * Race/Ethnicity Asian Black Hispanic or Latino Native American White Other Black-Asian Black-Hispanic Hispanic-Asian White-Asian White-Black White-Hispanic   Home Email* Applicant 2's General Information Last Name* * First Name* * Middle Name Email* * Applicant 2's Cell Phone ()-ext Enter Int'l Number Work Phone* ()-ext * Enter Int'l Number Occupation* * Gender* Female Male Please Specify *  If "Please Specify", please write gender here: Date of Birth* * Race/Ethnicity Asian Black Hispanic or Latino Native American White Other Black-Asian Black-Hispanic Hispanic-Asian White-Asian White-Black White-Hispanic   Legal Residence of Applicant(s) Street Address Street Address Line 2 City State/Region AK - Alaska AL - Alabama AR - Arkansas AS - American Samoa AZ - Arizona CA - California CO - Colorado CT - Connecticut DC - District of Columbia DE - Delaware FL - Florida FM - Federated States of Micronesia GA - Georgia GU - Guam HI - Hawaii IA - Iowa ID - Idaho IL - Illinois IN - Indiana KS - Kansas KY - Kentucky LA - Louisiana MA - Massachusetts MD - Maryland ME - Maine MH - Marshall Islands MI - Michigan MN - Minnesota MO - Missouri MP - Northern Mariana Islands MS - Mississippi MT - Montana N/A - Not Specified NC - North Carolina ND - North Dakota NE - Nebraska NH - New Hampshire NJ - New Jersey NM - New Mexico NV - Nevada NY - New York OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania PR - Puerto Rico PW - Palau RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VA - Virginia VI - Virgin Islands VT - Vermont WA - Washington WI - Wisconsin WV - West Virginia WY - Wyoming Enter Region Zip Code County Country United States Australia Cambodia Canada China Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Moldova Netherlands Russia Sweden Switzerland Ukraine United Kingdom Show All Countries Secondary Address of Applicant(s) Only enter a secondary (or mailing) address if it is different from the legal residence address. Street Address Street Address Line 2 City State/Region AK - Alaska AL - Alabama AR - Arkansas AS - American Samoa AZ - Arizona CA - California CO - Colorado CT - Connecticut DC - District of Columbia DE - Delaware FL - Florida FM - Federated States of Micronesia GA - Georgia GU - Guam HI - Hawaii IA - Iowa ID - Idaho IL - Illinois IN - Indiana KS - Kansas KY - Kentucky LA - Louisiana MA - Massachusetts MD - Maryland ME - Maine MH - Marshall Islands MI - Michigan MN - Minnesota MO - Missouri MP - Northern Mariana Islands MS - Mississippi MT - Montana N/A - Not Specified NC - North Carolina ND - North Dakota NE - Nebraska NH - New Hampshire NJ - New Jersey NM - New Mexico NV - Nevada NY - New York OH - Ohio OK - Oklahoma OR - Oregon PA - Pennsylvania PR - Puerto Rico PW - Palau RI - Rhode Island SC - South Carolina SD - South Dakota TN - Tennessee TX - Texas UT - Utah VA - Virginia VI - Virgin Islands VT - Vermont WA - Washington WI - Wisconsin WV - West Virginia WY - Wyoming Enter Region Zip Code County Country United States Australia Cambodia Canada China Ethiopia France Germany Guatemala India Ireland Italy Kazakhstan Mexico Moldova Netherlands Russia Sweden Switzerland Ukraine United Kingdom Show All Countries Marital Status Marital Status Married Single Divorced Widowed Domestic Partnership Engaged Separated   Date of Current Marriage Home Study Agency Current Home Study Documents* Document Uploaded Upload New/Replace Existing Name of Adoption Agency/Attorney Contact Person Phone ()-ext Enter Int'l Number Date Ended Date Home Study was completed. ASAP Preferences Preferred Race/Ethnicity No Preference Asian Black Caucasian East Indian Hispanic Middle Eastern Native American Other/Unspecified White   Preferred Gender Girl Only Boy Only Either Sex   Please select the age range(s) of child you envision parenting. Newborn under 6 months Baby/Toddler (6-24 months) Preschool (24-48 months) Elementary school (4-7 years) Older child (older than 7 years)   Medical Issues HIV Cerebral Palsy Severe Medical Problems Moderate Non-Correctable Medical Problems Extreme Prematurity Likely Moderate Cognitive Disabilities Down Syndrome Down Syndrome with Cardiac or Other Medical Complications Brain Anomalies Anticipated Cognitive Disabilities Known or Potential Alcohol Related Disabilities Heavy Alcohol Use by Birth Mother Heavy Drug Use by Birth Mother Infant Exhibiting Atypical Neurological Symptoms Child at High Risk for Mental Illness Child Diagnosed with Autism Blindness Shortened Life Expectancy Other Issues   Legal Risk Placement Case by Case Yes No   Openness Fully Open (all of the above) Skype and Telephone Contact Pictures and Letters via Email or Regular Mail Reunion Visits (1-2 per year) No Communication   Specific physical (medical) issues that you are comfortable with and why. Specific mental/cognitive issues that you are comfortable with and why. Special Needs Children - Experience Additional Information More about your family: anything else you wish to tell us? How did you hear about us? Abortion Clinic Adoption Agency Advertisement Child Welfare (ACS, CPS, etc.) Conference/Workshop Doctor Employer Family/Friend Hospital Delivered Hospital Pregnant I am personally connected to S-C Internet/Search Engine/Social Media Legal Services/Lawyer Magazine/Newspaper Maternity Residence Medical/Health Care Provider Planned Parenthood Rainbowkids Reputation Right-to-Life Org. School/Education Social Services Unreported   If Other, please explain. Do you have any specific questions or comments you would like to share?

Other Children in Home

Family Details | Other Children 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

	First Name	Last Name	Gender	If "Please Specify", specify gender here.
			Female Male Please Specify

	Date of Birth	Origin	Race/Ethnicity
		Adopted Biological Foster Child	Asian Black Hispanic or Latino Native American White Other Black-Asian Black-Hispanic Hispanic-Asian White-Asian White-Black White-Hispanic

	First Name	Last Name	Gender	If "Please Specify", specify gender here.
			Female Male Please Specify

	Date of Birth	Origin	Race/Ethnicity
		Adopted Biological Foster Child	Asian Black Hispanic or Latino Native American White Other Black-Asian Black-Hispanic Hispanic-Asian White-Asian White-Black White-Hispanic

	First Name	Last Name	Gender	If "Please Specify", specify gender here.
			Female Male Please Specify

	Date of Birth	Origin	Race/Ethnicity
		Adopted Biological Foster Child	Asian Black Hispanic or Latino Native American White Other Black-Asian Black-Hispanic Hispanic-Asian White-Asian White-Black White-Hispanic

	First Name	Last Name	Gender	If "Please Specify", specify gender here.
			Female Male Please Specify

	Date of Birth	Origin	Race/Ethnicity
		Adopted Biological Foster Child	Asian Black Hispanic or Latino Native American White Other Black-Asian Black-Hispanic Hispanic-Asian White-Asian White-Black White-Hispanic

	First Name	Last Name	Gender	If "Please Specify", specify gender here.
			Female Male Please Specify

	Date of Birth	Origin	Race/Ethnicity
		Adopted Biological Foster Child	Asian Black Hispanic or Latino Native American White Other Black-Asian Black-Hispanic Hispanic-Asian White-Asian White-Black White-Hispanic

	First Name	Last Name	Gender	If "Please Specify", specify gender here.
			Female Male Please Specify

	Date of Birth	Origin	Race/Ethnicity
		Adopted Biological Foster Child	Asian Black Hispanic or Latino Native American White Other Black-Asian Black-Hispanic Hispanic-Asian White-Asian White-Black White-Hispanic

	First Name	Last Name	Gender	If "Please Specify", specify gender here.
			Female Male Please Specify

	Date of Birth	Origin	Race/Ethnicity
		Adopted Biological Foster Child	Asian Black Hispanic or Latino Native American White Other Black-Asian Black-Hispanic Hispanic-Asian White-Asian White-Black White-Hispanic

	First Name	Last Name	Gender	If "Please Specify", specify gender here.
			Female Male Please Specify

	Date of Birth	Origin	Race/Ethnicity
		Adopted Biological Foster Child	Asian Black Hispanic or Latino Native American White Other Black-Asian Black-Hispanic Hispanic-Asian White-Asian White-Black White-Hispanic

	First Name	Last Name	Gender	If "Please Specify", specify gender here.
			Female Male Please Specify

	Date of Birth	Origin	Race/Ethnicity
		Adopted Biological Foster Child	Asian Black Hispanic or Latino Native American White Other Black-Asian Black-Hispanic Hispanic-Asian White-Asian White-Black White-Hispanic

	First Name	Last Name	Gender	If "Please Specify", specify gender here.
			Female Male Please Specify

	Date of Birth	Origin	Race/Ethnicity
		Adopted Biological Foster Child	Asian Black Hispanic or Latino Native American White Other Black-Asian Black-Hispanic Hispanic-Asian White-Asian White-Black White-Hispanic

	First Name	Last Name	Gender	If "Please Specify", specify gender here.
			Female Male Please Specify

	Date of Birth	Origin	Race/Ethnicity
		Adopted Biological Foster Child	Asian Black Hispanic or Latino Native American White Other Black-Asian Black-Hispanic Hispanic-Asian White-Asian White-Black White-Hispanic

	First Name	Last Name	Gender	If "Please Specify", specify gender here.
			Female Male Please Specify

	Date of Birth	Origin	Race/Ethnicity
		Adopted Biological Foster Child	Asian Black Hispanic or Latino Native American White Other Black-Asian Black-Hispanic Hispanic-Asian White-Asian White-Black White-Hispanic

	First Name	Last Name	Gender	If "Please Specify", specify gender here.
			Female Male Please Specify

	Date of Birth	Origin	Race/Ethnicity
		Adopted Biological Foster Child	Asian Black Hispanic or Latino Native American White Other Black-Asian Black-Hispanic Hispanic-Asian White-Asian White-Black White-Hispanic

	First Name	Last Name	Gender	If "Please Specify", specify gender here.
			Female Male Please Specify

	Date of Birth	Origin	Race/Ethnicity
		Adopted Biological Foster Child	Asian Black Hispanic or Latino Native American White Other Black-Asian Black-Hispanic Hispanic-Asian White-Asian White-Black White-Hispanic

	First Name	Last Name	Gender	If "Please Specify", specify gender here.
			Female Male Please Specify

	Date of Birth	Origin	Race/Ethnicity
		Adopted Biological Foster Child	Asian Black Hispanic or Latino Native American White Other Black-Asian Black-Hispanic Hispanic-Asian White-Asian White-Black White-Hispanic

	First Name	Last Name	Gender	If "Please Specify", specify gender here.
			Female Male Please Specify

	Date of Birth	Origin	Race/Ethnicity
		Adopted Biological Foster Child	Asian Black Hispanic or Latino Native American White Other Black-Asian Black-Hispanic Hispanic-Asian White-Asian White-Black White-Hispanic

	First Name	Last Name	Gender	If "Please Specify", specify gender here.
			Female Male Please Specify

	Date of Birth	Origin	Race/Ethnicity
		Adopted Biological Foster Child	Asian Black Hispanic or Latino Native American White Other Black-Asian Black-Hispanic Hispanic-Asian White-Asian White-Black White-Hispanic

	First Name	Last Name	Gender	If "Please Specify", specify gender here.
			Female Male Please Specify

	Date of Birth	Origin	Race/Ethnicity
		Adopted Biological Foster Child	Asian Black Hispanic or Latino Native American White Other Black-Asian Black-Hispanic Hispanic-Asian White-Asian White-Black White-Hispanic

	First Name	Last Name	Gender	If "Please Specify", specify gender here.
			Female Male Please Specify

	Date of Birth	Origin	Race/Ethnicity
		Adopted Biological Foster Child	Asian Black Hispanic or Latino Native American White Other Black-Asian Black-Hispanic Hispanic-Asian White-Asian White-Black White-Hispanic

	First Name	Last Name	Gender	If "Please Specify", specify gender here.
			Female Male Please Specify

	Date of Birth	Origin	Race/Ethnicity
		Adopted Biological Foster Child	Asian Black Hispanic or Latino Native American White Other Black-Asian Black-Hispanic Hispanic-Asian White-Asian White-Black White-Hispanic

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