The CHANGE Trust Adoption Society

Tel: 020 240 2909

Email: info@africachildrightscenter.org

Form for Enquiry on Prospective Adopter(s)

Particulars of female prospective adopter

Full names..........................................................................................................................................
Physical Address.............................................................................................................(attach map)
Email address.............................................................Telephone No..................................................
Postal address..............................................................Nearest Landmark..........................................

Date of birth........................... Place of birth...........................ID/Passport No. .................................

Occupation ........................................................................ Marital status..................................
Type of marriage (Christian, Islamic customary or other specify).....................................................
Form of marriage (polygamous, monogamous)..................................................................................
Date of marriage ...............................................Place of marriage....................................................
If married, do you intend to make a joint application for an adoption order? ...................................
If no, give reasons ..............................................................................................................................
Country of domicile..........................................................................Nationality...............................
Race........................................ Religion ...................:.........................................................................
Immigration status..............................................................................................................................
Length of previous residence in Kenya................................................. Intended length of future
residence in Kenya..............................................................................................................................
Income per month.................................................. other sources of income .....................................
How far is the earning of the children living in the home included in this
income?...............................................................................................................................................
.............................................................................................................................................................

Particulars of male prospective adopter

Full names.........................................................................................................................................
Physical Address.............................................................................................................(attach map)
Email address.............................................................Telephone No..................................................
Postal address..............................................................Nearest Landmark..........................................

Date of birth........................... Place of birth...........................ID/Passport No. .................................

Occupation ........................................................................ Marital status..................................
Type of marriage (Christian, Islamic customary or other specify).....................................................
Form of marriage (polygamous, monogamous)..................................................................................
Date of marriage ...............................................Place of marriage....................................................
If married, do you intend to make a joint application for an adoption order? ...................................
If no, give reasons ..............................................................................................................................
Country of domicile..........................................................................Nationality...............................
Race........................................ Religion ...................:.........................................................................
Immigration status..............................................................................................................................
Length of previous residence in Kenya................................................. Intended length of future
residence in Kenya..............................................................................................................................
Income per month.................................................. other sources of income .....................................
How far is the earning of the children living in the home included in this
income?...............................................................................................................................................
.............................................................................................................................................................

OTHER CHILDREN IN THE PROSPECTIVE ADOPTIVE FAMILY

Full names Date of birth Sex Occupation

1. ..................................... .................................. .............. ..........................
2. .................................... .................................. ............... ..........................
3. ..................................... ................................. ............... ..........................
4. ..................................... ................................. ............... ..........................

How many of the children are living at home?.........................................................................

What is the opinion of the children on the proposed adoption? .........................................................
Have you adopted a child(ren) before? Yes........................No..............................If yes, give details
Name Date of birth Sex Occupation
1. ........................ . ................................ ................ .......................
2. .......................... ................................ ................ .........................
3. ............................ ................................ ................ ..........................
Details of their health status................................................................................................................
Name and address of the adoption society that arranged the adoption..........................................
Has any previous application for adoption been rejected? Yes/No......... If yes give
reasons...............................................................................................................................................
ACCOMMODATION AND CONDITION OF THE HOME

Description of the home ..................................................................................................................

Number of bedrooms....................................................Source of water.............................................

Type of toilet/bathroom ....................................................................................................................
Type of house (permanent/ semi-permanent/ traditional) ..................................................................
Owner occupier/rented .......................................................................................................................
Assets/ property .................................................................................................................................
Liabilities (loan, mortgage etc) ..........................................................................................................
Details of other people living in the home:

Full names Age sex Relationship Occupation

1......................... ......... ......... ....................... .....................................
2. ...................... .......... ......... ....................... ......................................
3. ...................... ........... ......... ....................... ......................................

Are the people living in the home in apparent good health? .....................................................
What child do you wish to adopt? Age .......................... Sex ........................Race ....................
Other (specify) ............................................................. Would you welcome periodical visits by a
representative of an adoption society for a limited period after the adoption order is made?
Yes/No. .............. If no, give reasons
.............................................................................................................................................................

Give names of responsible persons who can vouch for your ‘character’ and means

Names Title/occupation Address Telephone/email

1......................... ............................... ..................... .......................................
2........................ ............................... ..................... .......................................
3........................ ................................ ..................... .......................................

I certify that the information given above is true to the best of my knowledge.

Name .................................................................................................................................................
Signature ............................................................................................... Date ....................................

Name .................................................................................................................................................
Signature ............................................................................................... Date ....................................