APPLICATION FOR INTERNATIONAL ADOPTION SERVICES

Welcome! We are so excited to begin our partnership with you. To ensure we have the information we need to best serve you, please take a few moments to fill out the form below. If you have any questions, please feel free to contact us at any time. Thank you!
Contact Information
Applicant 1

First NameMiddle NameLast Name
Gender

MFOther
Birthdate (m/d/y)

MonthDayYear
Date
Birth-place (City/Prov)
E-mail
Phone Number

Area CodePhone Number
Applicant 2

First NameMiddle NameLast Name
Gender

MFOther
Birthdate (m/d/y)

MonthDayYear
Date
Birth-place (City/Prov)
E-mail
Phone Number

Area CodePhone Number
PREFERRED CONTACT

PhoneE-mail
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Marital Status

SingleMarriedDivorcedLegally SeparatedOther
Date of Marital Status

MonthDayYear
Date
Place of Marriage
Additional Information
Please state the names and dates of birth of any children and/ or adults living in the home:
If you have adopted before state the year the child was adopted and child's country of origin:
Which country are you hoping to adopt a child or a sibling group and why?
If you are adopting a specific child (relative or other), please indicate full name, date of birth and who is parenting the child. Also indicate your relationship to the child (if any).
References: Please provide three (3) references who are personally acquainted with you and your home life. One (1) reference MUST be a relative; provide only one relative. All references must reside in Canada, but not necessarily in Alberta. Each of the references will initially be contacted by e-mail or mail, with follow-up contact being in person or telephone. Please discuss your adoption plans with your references and advise them that they will be contacted and asked to provide information about you in writing. NOTE: It is important to stress that your references reply promptly to any of our inquiries. If we do not receive information promptly, a delay will result in the commencement of your home assessment.
Reference 1

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
E-mail
RELATIONSHIP TO APPLICANTS

FriendFamilyCoworkerBusiness AcquaintanceNeighbour
Reference 2

First NameMiddle NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
E-mail
RELATIONSHIP TO APPLICANTS

FriendFamilyCoworkerBusiness AcquaintanceNeighbour
Reference 3

First NameMiddle NameLast Name
Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Email
example@example.com
RELATIONSHIP TO APPLICANTS

FriendFamilyCoworkerBusiness AcquaintanceNeighbour
International Adoption Education Component (Mandatory): Small Group Classes are VIRTUAL (online) from 9am-3pm). Please identify which adoption you are proceeding with:

Relative adoptionNonrelative adoption
Referred to Small Miracles By:
By signing below or submitting electronically, I hereby authorize Small Miracles Adoption to contact my references by telephone, mail, or email to provide them with the appropriate reference forms. I understand that once my references have completed the above mentioned forms, they will need to forward the original signed copy to Small Miracles Adoption.

Signature & Date of Applicant 1:

_____________________________________________________________________

Signature & Date of Applicant 2:

_____________________________________________________________________
Thank You From A Small Miracle Adoption.
I am ready to submit this form.*

Yes Submit This Form.
2024.12.01
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