New email address:jcan@qwestoffice.net

We recommend either: 1)print this registration form aout, fill it out and mail or fax it to us, or
    2)copy it to your word-processing program, fill it out, and e-mail, mail or fax it to us

PARENT REGISTRATION
 Thank you for expressing interest in the JCAN.  Your honest answers will enable us to do the best possible job in matching
available children to prospective parents.  All your answers will be kept in the utmost confidence.  We will contact you for permission
before referring you for any child.
NAME:___________________________________________________________________________________
                          registrant                                                                                      spouse
Mailing address:________________________________________________________________
                                                                                                                                  zip
Telephones:(             )                                                 (              )                                                 (               )
                                                   home                                            work/registrant                                                work/spouse
PERSONAL INFORMATION:
                                                                                           registrant                                        spouse
Birthdate and place..........................................__________________________....._________________________
Jewish by birth?...............................................__________________________....._________________________
If converted, when, by whom?..........................__________________________....._________________________
Previous marriage?If yes,how & when terminated?_________________________...._________________________
Race...............................................................__________________________....._________________________
Profession/employment............................__________________________....._________________________
Synagogue affiliation:____________________________________,affiliated with the________________movement,
 Rabbi:____________________________phone(          )                                             May we call?_________________
 Briefly describe your approach to Judaism and involvement in the Jewish community:_____________________
 ___________________________________________________________________________________
 Do you keep kosher?_______________are you vegetarian?______________Do you smoke?____________
I/We currently have________children.  Sex, age, adopted or biological:____________________________________
 ___________________________________________________________________________________
 ___________________________________________________________________________________
ADOPTION PREFERENCES:In order to help us match a child with your interests, we have listed a variety of situations/conditions
for your consideration.  Your answers will not affect your placement in our datafile, but, obviously, the more you are open to, the more
referrals we are likely to find for you.  Please feel free to add comments to this list directly on the sheet, or add further pages
(PLEASE put your name on any added pages and staple them to this form!)
 child under three months   [     ]yes  [     ]maybe [     ]no
 three to twelve months    [     ]yes  [     ]maybe [     ]no
 one to two years    [     ]yes  [     ]maybe [     ]no
 three to five years    [     ]yes  [     ]maybe [     ]no
 over six years old    [     ]yes  [     ]maybe [     ]no
 over ten years old    [     ]yes  [     ]maybe [     ]no
 male      [     ]yes  [     ]maybe [     ]no
 female      [     ]yes  [     ]maybe [     ]no

 Hispanic or part-Hispanic child   [     ]yes  [     ]maybe [     ]no
 Black or part-Black child    [     ]yes  [     ]maybe [     ]no
 Asian or part-Asian child    [     ]yes  [     ]maybe [     ]no
 American Indian or part-American-Indian child [     ]yes  [     ]maybe [     ]no
 (We do get a number of biracial children referred to us.  If your family is multiracial or transracial, please let us know    here:________________________________________________________________________)
A child: with mild to moderate mental retardation  [     ]yes  [     ]maybe [     ]no
 with severe to profound mental retardation [     ]yes  [     ]maybe [     ]no
 with Down syndrome    [     ]yes  [     ]maybe [     ]no
 with mild physical disability   [     ]yes  [     ]maybe [     ]no
 with moderate to severe physical disability [     ]yes  [     ]maybe [     ]no
 partially or totally blind    [     ]yes  [     ]maybe [     ]no
 partially or totally deaf    [     ]yes  [     ]maybe [     ]no
 with known limited life expectancy  [     ]yes  [     ]maybe [     ]no
 HIV positive     [     ]yes  [     ]maybe [     ]no
 with allergies     [     ]yes  [     ]maybe [     ]no
 with hemophilia     [     ]yes  [     ]maybe [     ]no
 with seizure disorders    [     ]yes  [     ]maybe [     ]no

 with mild emotional problems   [     ]yes  [     ]maybe [     ]no
 with moderate to severe emotional problems [     ]yes  [     ]maybe [     ]no
 with mild learning disabilities   [     ]yes  [     ]maybe [     ]no
 with moderate to severe learning disabilities [     ]yes  [     ]maybe [     ]no
 with attention deficit/hyperactivity disorder [     ]yes  [     ]maybe [     ]no

 who has been physically abused  [     ]yes  [     ]maybe [     ]no
 who has been sexually abused   [     ]yes  [     ]maybe [     ]no
 who has been sexually active   [     ]yes  [     ]maybe [     ]no
 exposed to drugs or alcohol in utero  [     ]yes  [     ]maybe [     ]no
 who has used drugs or alcohol   [     ]yes  [     ]maybe [     ]no
 who is autistic     [     ]yes  [     ]maybe [     ]no

 with a family history of mental illness  [     ]yes  [     ]maybe [     ]no
 with a family history of emotional illness  [     ]yes  [     ]maybe [     ]no
 product of a rape    [     ]yes  [     ]maybe [     ]no
 product of incest    [     ]yes  [     ]maybe [     ]no
 with no known father’s medical history  [     ]yes  [     ]maybe [     ]no
 not yet legally free for adoption   [     ]yes  [     ]maybe [     ]no
 non-Jewish child    [     ]yes  [     ]maybe [     ]no
Would you be interested in serving as a foster parent/family for a Jewish child?_______________________________
If you have any special qualities you’d like to mention, please use this space(and feel free to add other pages):
 
 
 

Have you had a home study?_______If so, when and by whom?__________________________________________
 (If you have not had a home study, we strongly recommend you initiate one as soon as possible so you are ready should an
appropriate child become available on short notice.  Contact local adoption agencies or social workers for more information
    on home studies in your state.)
PLEASE READ AND SIGN:   In registering with the Jewish Children’s Adoption Network, I/we understand that the
JCAN is not an adoption agency.  It is a recruitment and referral organization, primarily of parents for children with “special needs”.
These children may be older, have mental, physical or emotional disabilities, of mixed ethnic background, or be part of a sibling group.
While the JCAN certainly cannot promise to locate an appropriate child for me/us, I/we understand that its goal is to expedite and encourage,
to the extent that it is able, the placement of available Jewish children in Jewish homes.   If the JCAN locates a child matching what I/we have
indicated on this form, it will contact me/us to find out if I/we wish to be put in contact with the child’s social worker.  A “no” will not affect
future referrals.   I/we further understand that any information given by us to the JCAN will be kept in strict confidence, and will only be used
as needed to help in matching me/us to any available children.  I/we also understand that any information about any child referred to me/us
should be confirmed by me/us with the custodian agency, as the JCAN does not have total access to the child’s records, and, therefore, cannot
verify the accuracy of information received or be responsible for errors or omissions of any attorney, social worker, or agency.

        ________________________________________
        registrant    date

        ________________________________________
        spouse     date

 While the JCAN has no fee for registering parents, as we wish to encourage as many interested parents as possible to be in our database,
we can only continue our work with the financial support of those we seek to serve.  We would appreciate any donation, large or small, and
would suggest $36 as a reasonable average donation.  As a 501c3 corporation, all donations to the JCAN are tax deductible to the
fullest extent allowed by law.

        Thank you, and much hatzlacha,
        Jewish Children’s Adoption Network