A CHILD WAITS FOUNDATION ~ Grant Pre-Application Form
1136 Barker Rd, Unit 12  Pittsfield, MA  01201  Phone: 866-999-2445
Fax: 518-794-6243  Email: cnelson@achildwaits.org  Web: www.achildwaits.org
Name:            Home Phone: _________________ Date: _______________
Address: _____________________________________________________________________________
Applicants' Information
First Name Age Occupation Cell #
       
       
Last Year's Income: $        Own Home                  Rent Savings: $
Projected Current Year's Income: $      Home Equity: $   Retirement: $
After paying bills each month, how much money is left?  Investments: $
                   
Child to be Adopted:  Country: __________       Expected Travel Date: __________________________
Name Age Sex Special Need
       
       
       
                   
Total cost for adoption including home study and travel: $ ___________________
Amount paid to date: $ ___________________
Of amount paid, how much has been from your own savings/earnings? $ ___________________
Funds currently available (i.e., personal savings or fundraising): $ ___________________
What other grants, loans, agency reductions or church support have you applied for or received?  
Please list amounts and providers below.
Funding Source Amount Approved Funds Received Still Pending Grant/Loan/ Donation
1   Yes                No     Yes                  No        Yes       No  
2   Yes                No     Yes                  No        Yes       No  
3   Yes                No     Yes                  No        Yes       No  
4   Yes                No     Yes                  No        Yes       No  
Are family and friends providing financial help with this adoption?    Yes _______  No _______
Name Amount Name Amount
1)       3)      
2)       4)      
 
Grant Pre-Application Form - Page 2 Name  
Current Family Profile
Number of Children:  Adopted: _____            Bio: _____   Number of children at home: ___________
   
Do you have any children with special needs? Yes   No    
   If yes, please explain:                
   
Name of Adoption Agency:      
Name of Home Study Agency:      
Is Home Study Complete?  Yes _____     No _____
Are there any past credit issues, such as bankruptcy or late payments?  Yes ______   No ______
     If yes, please explain: _________________________________________________________________
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 ____
Special Family/Financial Circumstances to be Considered:        
                   
                   
                   
                   
                   
                   
                   
If the child or children to be adopted are under the age of 4 please include picture and medical information.
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.