YOU ARE

Applicant 1

YOU ARE

Applicant 2

APPLICATION DATE

YYYY

1. DETAILS APPLICANT ONE

FULL NAMES APPLICANT ONE (as indicated on your ID/Passport)

First Name

Last Name

1.1 Tel No. (Work)

1.2 Tel No. (Home)

1.3 Mobile No.

1.4 E-mail address

1.5 Identity Number or Passport Number

1.6 Age

1.7 Race / Cultural ethnicity

1.8 Gender

1.9 Home language

1.10 Citizenship

NON- RSA CITIZENS MUST PROVIDE PROOF OF PERMANENT RESIDENCY, WE CANNOT CONSIDER ANY APPLICATIONS WITHOUT THIS

1.11 Religion (If applicable)

1.12 Marital Status

1.13 Date of Marriage

(If applicable)

1.14 Residential Address

Applicants who are not able to attend sessions at our Consulting Rooms in Wellington cannot apply

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

1.15 Occupation and Monthly Income

2. DETAILS OF APPLICANT TWO

Full Names (as indicated on your ID/Passport)

First Name

Last Name

2.1 Tel No. (Work)

2.2 Tel No. (Home)

2.3 Mobile No.

2.4 E-mail address

2.5 Identity Number or Passport Number

2.6 Age

2.7 Race / Cultural ethnicity

2.8 Gender

2.9 Home language

2.10 Citizenship

NON- RSA CITIZENS MUST PROVIDE PROOF OF PERMANENT RESIDENCY, WE CANNOT CONSIDER ANY APPLICATIONS WITHOUT THIS

2.11 Religion (If applicable)

2.12 Marital Status

2.13 Residential Address

If it differs from Applicant One

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

2.14 Occupation and Monthly Income

3. WHY DO YOU WANT TO ADOPT A CHILD?

4. DO YOU KNOW OR ARE YOU RELATED TO THE CHILD OR THE BIOLOGICAL PARENT/S OF THE CHILD YOU WISH TO ADOPT?

Yes

If yes, please provide details (E.g. Family, Step parent, Foster child)

5. IF YOU WISH TO ADOPT A CHILD UNKNOWN TO YOU, PLEASE INDICATE YOUR PREFERENCE

5.1 Age

5.2 Gender

Male

Female

No preference

5.3 Race

Black

White

Coloured

Mixed Race (where the father and mother belongs to a different race group)

Indian

No preference

5.4 Other preferences: Please indicate here if you have any other preferences or comments regarding the child you wish to adopt

6. HAVE YOU ADOPTED A CHILD OR CHILDREN BEFORE?

Yes

If yes, please provide: Name/s and Surname/s, Date of Birth and Date placed in your care

7. ARE YOU OR WERE YOU INVOLVED WITH ANY OTHER ORGANISATION OR SOCIAL WORKER REGARDING ADOPTIONS?

Yes

If yes, please provide Organisation / Social worker details below

Date of last contact with the Organisation / Social worker

YYYY

PLEASE NOTE THAT WE WILL NOT BE ABLE TO CONSIDER YOUR APPLICATION IF YOU HAVE ALREADY BEEN (OR ARE STILL IN THE PROCESS) OF SCREENING. YOU WILL HAVE TO PROVIDE WRITTEN PROOF OF TERMINATION OF SUCH SERVICES BEFORE WE WILL ACCEPT YOUR APPLICATION.

8. DO YOU HAVE ANY BIOLOGICAL CHILDREN?

Yes

If yes, please provide: Name/s and Surname/s and Date of Birth

9. ANY OTHER COMMENTS OR INFORMATION YOU WISH TO PROVIDE?

DISCLAIMER

I/we understand that once PROCARE has received my/our application form, I/we might not be invited to attend an Orientation session for various reasons, E.g. the waiting lists are closed, services are not provided in your area. PROCARE will not enter into any communication in this regard and I/we understand that I/we should contact PROCARE to enquire about the status our application if I/we received no response within two weeks after my/our application form has been submitted. I/We acknowledge that if I/we are invited to attend an Orientation session, the Social Workers involved will assess my/our suitability for adoption and they will advise me/us accordingly during the session. I/we understand that PROCARE cannot guarantee that I/we would qualify to be screened as an adoptive parent(s) and there will be no obligation whatsoever for the Adoption Unit to continue with the process. I/we agree that the fees charged are non-refundable and are charged for the services of PROCARE and the Social Workers involved, no fee/money can be paid to biological parents/family or paid for babies.

Disclaimer agreement: APPLICANT 1

I AGREE

I DISAGREE

Disclaimer agreement: APPLICANT 2

I AGREE

I DISAGREE

PROCARE ADOPTION UNIT
Wellington, Western Cape

APPLICATION FORM

PROCARE ADOPTION UNIT Wellington, Western Cape

APPLICATION FORM

PROCARE ADOPTION UNIT
Wellington, Western Cape