Journeys of the Heart
 
Online Application
  

Application load/save

Please tell us how you first heard- About Journeys of the Heart.  Enter your answer into the box on the right.

Because this is a long application, we've added the ability for you to save the state of your application and continue later, even from a different computer if you wish. When saved, your information is stored solely for the purpose of you retrieving it later, and nothing else. If you use this feature, pick a password you will remember, as it will not be possible to retrieve your stored information without it, and you'll have to start over. If a login is not used within 5 weeks of it's last use, the login and it's stored data will be deleted.

 

Login

Password

(must be at least 5 characters)

  previously saved data

  your application to continue later

Personal Information

Applicant Name(s)

First(husband)    M.I   Last 

 

First(wife)   M.I   Last 

Address
City
State
Zip Code
Email
Home Phone - -
Work Phone(1) - -
Work Phone(2) - -
Fax - -
Date of Marriage (mm/dd/yyyy) - -  
Place of Marriage  
  Husband Wife
Social Security Number - - - -
Date of Birth (mm/dd/yyyy) - - - -
Place of Birth
Age
Height ft in ft in
Weight (pounds)
Occupation(s)
Place of Employment
Work Schedule
Yearly Income $ .00 $ .00
Religion
Ethnicity
Education (completion)
Insurance Coverage
Children:
Name Birth Date
(mm/dd/yyyy) 		Relationship Living at home
(Y/N)
Others living in your home and their relationship to you:
Name Birth Date
(mm/dd/yyyy) 		Relationship

Have either of you ever been arrested or convicted of a crime?     If yes, Please explain.

Do you have any religious or philosophical beliefs that would
prevent you from getting medical treatment for your child?     If yes, Please explain.

Please list four personal references whom have known each
of you at least two years -- one may be a relative.
Name Phone Number
- -
- -
- -
- -
Maternity &Paternity Plan: Explain how you intend to care for your child when he/she first arrives home including work and child care. (Journeys strongly recommends three months minimum time with the mother and/or father at home with the child before work is resumed).  
To which program are you applying? (domestic or international) If international, what country? What age and gender of child is preferable to you?

Are you open to a special needs child?     If yes, what special needs would you accept?

Please list several of your closest friends or relatives, including phone numbers, who usually know your whereabouts. When it is necessary to reach you and regular means fail, we will contact these people.
Name Phone Number
- -
- -
- -
Does anyone in your household, now or in the past, have a problem with alcohol, drugs, gambling, or any other addiction?
If yes, please describe the problem, treatment and current situation.
Does anyone in your home have any health problems?
If yes, please discuss:
Have any of your children been arrested?
If yes, list dates, charges and subsequent incarcerations or punishments:

Father Information:
Have you been married before?
If yes, please give names, dates of marriages and divorces:
List any children from previous marriages and who they live with:
If not in your custody, what is your relationship with your children?

Mother Information:
Have you been married before?
If yes, please give names, dates of marriages and divorces:
List any children from previous marriages and who they live with:
If not in your custody, what is your relationship with your children?

FINANCES
List all assets including mortgage values, savings, stocks and bonds, real estate, cars and personal possessions:
Describe your average monthly income: Gross Net
Mother $ .00 $ .00
Father $ .00 $ .00
Other $ .00 $ .00
(auto)Total $ .00 $ .00
Describe your monthly debts:  
House Payment $ .00
Utilities $ .00
Child Care $ .00
Food $ .00
Doctors / Dentists $ .00
Child Support $ .00
Union or other organization support $ .00
Health Insurance $ .00
School Tuition $ .00
Recreation $ .00
Church $ .00
Savings $ .00
Loans and credit cards $ .00
Car Payments $ .00
Gas and car upkeep $ .00
Magazines and newspapers $ .00
Support of Relatives $ .00
Life Insurance $ .00
Other $ .00
(auto)Total $ .00
Describe credit card debt:
Have you ever filed for bankruptcy?
If yes, please explain when and which chapter:
 
By check-marking this box, We (husband & wife) certify that all the information given here is accurate and complete. We understand the placement of a child is not guaranteed.

In order for your application to move forward, you are required to submit a $250 non-refundable deposit.  No action on any applications take place until the deposit is received.

Once we have received your completed application and your deposit, the Adoption Coordinator will review your application and contact you.

Once you submit your application online, you have the option of paying your deposit online.  To do so please go to the program page of the program you will be working with.

Three other items you need to submit to us soon:

1. Two pictures of applicants and family (snapshots only).  Photos can be no older than six months.
2. One picture of outside of house.
3. A copy of your home study (when completed).

Press The Button Below To Submit Your Application
Application submission