HCRM - Petionville, Haiti

Application To Adopt

Ayiti Enfants Sauver Mission

Rue Pelerin 9, Petion-ville, Haiti
011 509 445 1961 or 011 509 419 0480 or 011 509 449 0948

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General Information

Application date:

Father (full name):		Date of Birth:
Mother (full name):		Date of Birth:

Marital status:

single married divorced remarried

Date of Marriage:
*Home Address:
Phone Number:
*Email address:
Spouse Email address:

Husband's Information
Place of Employment:
Position:
Annual Income:
Phone:

Wife's Information
Place of Employment:
Position:
Annual Income:
Phone:

Names of children living with you:

Name	Age	Adopted (yes/no)

Religious Information

Religion/Denomination:
Are you active in a Church (yes/no):
Name of Church:
Pastor's name:
Pastor's Phone Number:
Pastor's Email address:

Which of the following terms best describes your present religious experience (check all that apply)?

born-again	attend church regularly
evangelical	attend Sunday school
do not attend a church at this time	non-traditional church

Describe your personal relationship with Jesus Christ:

Reference Information (required)

Please provide name, phone number, addresses, emails (if available) for four references including one member of your immediate family.

Name	Phone Number	Address	Email

Have you ever submitted an application for adoption to any agency and
been rejected for any reason?

If yes, please indicate the name of the agency and the reason.

Child Information

If seeking one child:	Child age (min to max):		Sex of desired child:
If seeking more than one child:	Child/sibling group (min to max):		Sexes of children:

Reason for wanting to adopt:

Reason you chose Haiti:

Please check those that you will consider:

	None			Down's Syndrome
	Cleft lip/palette			Visually impaired
	Sickle Cell Anemia Carrier			Speech impaired
	Learning disabled			Cerebral Palsy
	Low Birth Weight			Non-correctable handicap
	Hearing Impaired			Others

It is required by Haiti Children's Rescue Mission that at least one parent travel to Haiti to pick up their child. Are you willing to travel to Haiti? (yes/no):

If you are unable to travel to Haiti, please state why:

Statement of Faith and Purpose

The board of Ayiti Enfants Sauver Mission (HCRM) is dedicated to seeking and to finding stable, Christian homes for the children. The board of HCRM is committed not only to the children, but to their birth parents, to find homes where the children will be taught the love and the truth of Jesus Christ.

We believe the Bible is the word of God, the absolute authority and without error, that there is one God, who exists eternally in three persons: the Father, the Son, and the Holy Spirit. We believe that Jesus Christ is the eternal Son of God, who through His perfect life and sacrificial death paid the price for the sins of all who will trust in Him, alone, for salvation. We believe that all aspects of our lives are to be lived to the glory of God under the Lordship of Jesus Christ.

Completing this application does not guarantee acceptance to adopt a child/children through "Haiti Children's Rescue Mission."

Do you agree with the above statement of faith and purpose?

yes

Signature:			Date:			Initials:
Signature:			Date:			Initials:

Please print a copy of this
application before submitting.

Please send signed copy to:

HCRM c/o
Pastor Jean Fritz and Mrs. Mireille Nicolas
Lynx Air International
PO Box 407139
Fort Lauderdale, FL 33340-7139