Sharing the Journey Request for Information

__________________________________________________________________
Name of person requesting information

__________________________________________________________________
Address

______________________
City, State and Zip

___________________________
E-mail Address

______________________
Phone Number

___________________________
Secondary Phone

Preferred Method/s of Contact: _____ Phone _____ Secondary Phone
_____ Email

Looking to Connect with ...

Geographical areas willing to travel to, if applicable:
_________________________________________________________________

Check all that apply:

__ Adoptee
__ Adoptive family
__ Birth parent/family
__ Foster family
__ Prospective adoptive parent
__ Blended family
__ Single-Parent
__ Gay/Lesbian
__ Transracial
__ Semi-open adoption
__ Open adoption
__ Adoption professional

__ Have adopted child(ren) born in the US
__ Have adopted child(en) internationally
__ Decided against searching
__ Considering searching
__ In process of searching
__ Searched and found
__ Searched but not found
__ Have met birth family
__ Have met my child/ren's adoptive family/ies
__ Living in reunion
__ Other: _______________

Agency used _____________________

If Birth family, role _______________

Looking to Connect with Families with child/ren:

From
 ______________
Country/State of origin		 Age(s)
 ______________
Present Age		 ______________
Placement Age		 M/F
Circle one		 _____________
Special Needs

Please feel free to submit additional information. Use back or additional pages if necessary.