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APPLICATION

Applicant's First Name:
Applicant's Middle Name:
Applicant's Last Name:
Previous/Other Surname:
Birth Date(dd/mm/yy):
 
Home Phone Number:
- -
Cell Number:
- -
Email Address:
Address - Street:
Town/City:
Postal Code:
If you have lived at this address for less than 10 years, list previous addresses:
1. Address - Street:
Town/City:
Postal Code:
2. Address - Street:
Town/City:
Postal Code:
3. Address - Street:
Town/City:
Postal Code:
Gender:
Male Female
Languages Spoken in Home:
 
Currently practicing faith?
Yes No
If yes, what is religion practiced?
Racial Origin:
Education (What level of education have you reached?)
Occupation:
Place of Employment:
Business Phone Number:
- -
Have you ever received services or had involvement with a Children's Aid Society in Ontario or a child welfare agency outside of Ontario? Yes No
Have you ever applied to adopt before? Yes No
Co-Applicant's First Name:
Co-Applicant's Middle Name:
Co-Applicant's Last Name:
Previous/Other Surname:
Birth Date(dd/mm/yy):
 
Home Phone Number:
- -
Cell Number:
- -
Email Address:
Address - Street:
Town/City:
Postal Code:
If you have lived at this address for less than 10 years, list previous addresses:
1. Address - Street:
Town/City:
Postal Code:
2. Address - Street:
Town/City:
Postal Code:
3. Address - Street:
Town/City:
Postal Code:
Gender:
Male Female
Languages Spoken in Home:
 
Currently practicing faith?
Yes No
If yes, what is religion practiced?
Racial Origin:
Education (What level of education have you reached?)
Occupation:
Place of Employment:
Business Phone Number:
- -
Have you ever received services or had involvement with a Children's Aid Society in Ontario or a child welfare agency outside of Ontario? Yes No
Have you ever applied to adopt before? Yes No
Relationship:
Single, never married
Married
Living common-law

Same-sex couple
Divorced

Separated
Widowed
Children in the home:
Name as per birth registration Sex (m/f) Birth Date (dd/mm/yy) Grade Name of School/Occupation
1.
2.
3.
4.
Other persons currently living with family:
Name Birth Date (dd/mm/yy) Relationship
1.
2.
3.
4.

Certification
I/We declare:
1. That the information contained in this application is complete and true to the best of my/our knowledge and that a false statement may disqualify my/our application from further consideration.

2. An acknowledgement that a criminal record check will also be required. (The existence of a criminal record check will not necessarily result in an exclusion from the program.)

Consent*
    I/We acknowledge that I have read and understand the information outlined below.
    I/We consent to having my data entered into CPIN.
    I/We consent to the Society completing a provider search, using the identifying information provided in this application.

*We utilize a province wide database system to capture information about care-giving families, including adoption applicants, foster and kin families. This database is shared across the province of Ontario with other Children's Aid Societies and it is known as the Child Protection Information Network (CPIN). When an individual applies to become an adoptive parent, their identifying information is entered into this database. To continue with the adoption application, the individual(s) will be asked to consent to the collection of their information in CPIN and to a search of the CPIN database. All approved adoptive parents involved with The York Region Children's Aid Society will be registered in CPIN. By submitting the application, you are consenting to the collection of your identifying information and to having this information inputted into the CPIN database. In addition, you are consenting to the Society completing a provider search using your identifying information. This will ensure that duplicate records are not created and will confirm whether you have had any previous involvement with a Children's Aid Society as an adoptive, foster or kin parent. For more information about the CPIN database, please review the Notice of Information Practices, which outlines CPIN, information collected, and how it is used and shared.