<p>CSO-1068A (8-14) Page 1 of 3 ACY-1308A (9-13) ARIZONA DEPARTMENT OF CHILD SAFETY Adoption Registry FAMILY INFORMATION FOR INPUT INTO THE ADOPTION REGISTRY DATE OF APPLICATION</p><p>PARENT #1 ADOPTIVE PARENT’S NAME (Last, First, M.I.) DATE OF BIRTH SOC. SEC. NO.</p><p>ADDRESS (No., Street, City, State, ZIP) PHONE NO. (Home) PHONE NO. (Work)</p><p>MARITAL STATUS OCCUPATION If married, date: ETHNICITY ARE YOU BILINGUAL? Asian Black or African American American Indian / Alaska Native Yes No Hawaiian or other Pacific Islander Hispanic / Latino If yes, what language(s)? Non-Hispanic/Non-Latino White Other: RELIGION EDUCATION SCHOOL DISTRICT Elementary School: High School: PARENT #2 ADOPTIVE PARENT’S NAME (Last, First, M.I.) DATE OF BIRTH SOC. SEC. NO.</p><p>ADDRESS (No., Street, City, State, ZIP) PHONE NO. (Home) PHONE NO. (Work)</p><p>OCCUPATION</p><p>ETHNICITY ARE YOU BILINGUAL? Asian Black or African American American Indian / Alaska Native Yes No Hawaiian or other Pacific Islander Hispanic / Latino If yes, what language(s)? Non-Hispanic/Non-Latino White Other: RELIGION EDUCATION</p><p>HOUSEHOLD MEMBERS INFORMATION Name Date of Birth Gender Relationship to Applicant Ethnicity M F M F M F M F M F M F M F M F M F M F M F M F M F M F DATE OF COURT CERTIFICATION (If applicable) EXPIRATION DATE</p><p>CHILD(REN) DESIRED Age(s) of Number of Ethnicity of Primary Language Gender Siblings Child(ren) Children Child(ren) of Child(ren) Male Female Yes</p><p>No Preference No See page 3 for EOE/ADA/LEP/GINA disclosures</p><p>CSO-1068A (8-14) DEPARTMENT OF CHILD SAFETY (DCS) Page 2 of 3 Central Adoption Registry</p><p>Family is willing to care for a child with the following:</p><p>Abusive to Animals Depression Physical Disability Adjustment Disorder Developmental Disability Post-Traumatic Stress Disorder Affective Disorder Diabetes (PTSD) AIDS Downs Syndrome Pregnant Teen Alcohol Exposed Dwarfism Psychotic Disorder Allergies Dyslexia Reactive Attachment Disorder (RAD) Anorexia Encopresis Respiratory Problems Amputee Enuresis Safe-Haven / Unknown Anemic Failure to Thrive Schizophrenia Anxiety Disorder Feeding Issues Scoliosis Apnea Monitor Fetal Alcohol Spectrum Disorder Seizure / Epilepsy Arthritis (FASD) Self-Abusive Asperger’s Syndrome Fetal Alcohol Syndrome (FAS) Separation Anxiety Disorder Asthma Hearing Impaired Sexually Transmitted Disease Attachment Disorder Heart Problem Sexual Abuse Perpetrator Attention Deficit Disorder (ADD) History of Abuse or Neglect Sexual Abuse Victim Attention Deficit Hyperactive HIV Positive Sexually acts out-Masturbates Disorder (ADHD) Hoarding in Public Autistic Hydrocephalus Sexually Acts Out/Provocative Behaviors Impulse Control Disorder Behavior Aggressive Inappropriate Interactions Shaken Baby Syndrome Confrontational with Strangers Sickle Cell Anemia Damages Property Irritable Bowel Syndrome (IBS) Sickle Cell Trait Fire Setting Kidney Disease Smoking Physically Acts Out W/Adults Learning Disability Speech / Language Disorder Physically Acts Out W/Peers Lying Special Development Disorder Runs Away Loss Issues Special Diet Blind Mental Illness in Birth Family Special Education Bipolar Disorder Microcephaly Spina Bifida Cerebral Palsy Muscular Dystrophy Stealing Cognitive Disability Neurofibromatosis Substance Exposed Infant Conduct Disorder Obsessive Compulsive Disorder Substance Abuse Craniofacial Anomalies (OCD) Teen Parent Cystic Fibrosis Organic Disorder Terminal Illness Deaf Orthopedic Disorder Tourette’s Syndrome Deformity / Physical Oppositional Defiant Disorder Truancy Delinquency Paralysis Visually Impaired Pervasive Development Disorder Wheel Chair</p><p>FOR ADOPTIVE AGENCY OFFICE USE ONLY AGENCY NAME WORKER’S NAME PHONE NO. EMAIL ADDRESS</p><p>Expiration Date of Family selected would like to Family removed from Home Study or Court Family on Hold remain on the registry? Adoption Registry Certification Date: Date: Yes No Reason: Reason: Equal Opportunity Employer/Program • Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (ADA), Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. The Department must make a reasonable accommodation to allow a person with a disability to take part in a program, service or activity. For example, this means if necessary, the Department must provide sign language interpreters for people who are deaf, a wheelchair accessible location, or enlarged print materials. It also means that the Department will take any other reasonable action that allows you to take part in and understand a program or activity, including making reasonable changes to an activity. If you believe that you will not be able to understand or take part in a program or activity because of your disability, please let us know of your disability needs in advance if at all possible. To request this document in alternative format or for further information about this policy, contact your local office; TTY/TDD Services: 7-1-1. • Free language assistance for department services is available upon request.</p>