ADOPTING PARENTS:

Mothers full name:                   Age:

Fathers full name:                    Age:

Address:

E-mail address:

Date you moved to Clark County, Nevada?

Father?

Relationship to Adoptive Child(ren):

NATURAL MOTHER:

Date of birth:

Will mother sign a Consent to Adopt?

Full Name:

Date of birth:                                              

Home Address:

Will father sign a Consent to Adopt?

ADOPTIVE CHILD(REN)

Full Name of child(ren):

Date of Birth:                          Age:

How long child(ren) lived with adoptive parents:

Is this child of Indian descent?