A CHILD WAITS FOUNDATION ~ GRANT PROGRAM
1136 Barker Rd, Unit 12  Pittsfield, MA  01201  Phone: 866 999-2445
Fax: 518-794-6243  Email: cnelson@achildwaits.org  Web: www.achildwaits.org
Grant Applicant Pre-Qualification Form
Name:					Date:			Email: _______________
Address: _____________________________________________________________________________
Contact #'s:   Home: _________________    Work: ___________________    Cell: ___________________
Last Year's Income:  _____________     Current Year's Income: _____________								Own Home___   Rent____
Home Equity: $_________    Savings: $__________    Retirement: $_________    Investments: $________
After paying bills each month, how much money is left? ___________
Adoption Agency/Contact Name/#:
Home Study Agency/Contact Name/#:
Date of Home Study Completion:						Expected date of Travel?
Are there any past credit issues, such as bankruptcy or late payments?  Yes ______   No ______
If yes, please explain: _________________________________________________________________
Child(ren) to be Adopted
Country:				Is child(ren) in orphanage _____ or foster care _____ ?
Please complete the following for child(ren) being adopted.
Name		Age	Sex	Special Need				Is this a waiting child?
								Yes ____   No ____
								Yes ____   No ____
Have you had child's referral evaluated by a US International Adoption Specialist?  Yes ____  No ____
If yes, do you have a written report? Yes ____  No ____
Current Family Profile
Married		Single		# of Children:		Adopted: _______		Biological: _______
Do you have any children with special needs?					Yes		No
If yes, please explain:
Have you been approved by any bank, agency, church or foundation for financial help with this adoption?
	Yes		No			If yes, please complete amounts below.
Name			Amount		Name			Amount
1)					3)
2)					4)
Are family and friends providing financial help with this adoption?    Yes _______  No _______
Name			Amount		Name			Amount
1)					2)
Total cost for adoption including home study and travel:							$
Amount paid to date:							$
Funds currently available (i.e., personal savings or fundraising):							$
Special Family/Financial Circumstances to be Considered:
If the Foundation determines that you meet the prequalification requirements, you will be contacted to receive an application.  Please note that meeting the preliminary qualifications does not guarantee grant approval or funding.