York Region Children's Aid Society | Protecting Children and Strengthening Families

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APPLICATION

Applicant's Name (Surname/First/Middle):
Previous/Other Surname:	Birthdate(dd/mm/yy):
Address (including postal code):	Telephone Number:
If you have lived at this address for less than 10 years, list previous addresses: 1. 2. 3.
Gender: Male Female	Languages Spoken in Home:
Currently practicing faith? Yes No	If yes, is religion practiced?
Racial Origin:
Education (What level of education have you reached?)
Occupation:	Place of Employment:
Business Telephone #:	Email Address:
Have you ever received services from Child Welfare? Yes No	Have you ever applied to adopt before? Yes No

Co-Applicant's Name (Surname/First/Middle):
Previous/Other Surname:	Birthdate(dd/mm/yy):
Address (including postal code):	Telephone Number:
If you have lived at this address for less than 10 years, list previous addresses: 1. 2. 3.
Gender: Male Female	Languages Spoken in Home:
Currently practicing faith? Yes No	If yes, is religion practiced?
Racial Origin:
Education (What level of education have you reached?)
Occupation:	Place of Employment:
Business Telephone #:	Email Address:
Relationship: Single, never married Married Living common-law Same-sex couple	Divorced Separated Widowed
Have you ever received services from Child Welfare? Yes No	Have you ever applied to adopt before? Yes No

Children in the home:
Name as per birth registration	Sex (m/f)	Birth Date (dd/mm/yy)	Grade	Name of School/ Occupation
1.
2.
3.
4.

Other persons currently living with family:
Name	Birth Date (dd/mm/yy)	Relationship
1.
2.
3.
4.

Certification
I/We declare:
1. That the information contained in this application is complete and true to the best of my/our knowledge and that a false statement may disqualify my/our application from further consideration.

2. An acknowledgement that the Children's Aid Society will check internal records for any information relevant to this application and that a criminal record check will also be required. (The existence of a criminal record check will not necessarily result in an exclusion from the program.)