Application for Adoption (To be submitted in triplicate) From: To: The Director / Commissioner, Women Development and Child Welfare Department, AP Hyderabad. Sir / Madam, Sub:-Adoption of a child from Sisuvihar of Women Development a nd Child W elfare Department --Reg. * * * We have no children. We wish to adopt a child from Sisuvihar of Women Development and Child Welfare Department. 1 a. Name of the Husband b. Age c. Occupation 2 a. Name of the wife b. Age c. Occupation d. Address 3 Monthly Income of (*) a. Husband b. Wife 4 Properties (of both wife & husband) a. Movable Immovable (copy of the deed to be enclosed) 5 Liabilities of a. Husband b. Wife 6 Other members of the family 7 Savings 8 Description of the child for adoption a. Age b. Sex 9 Reasons for taking the child for adoption 10 Any other information SIGNATURE STATION: DATE Note: - (*) Certificate to be enclosed in support of the income, both wife and husband has to be signed. * * * * * * * MEDICAL FITNESS CERTIFICATE FOR ADOPTIVE PARENTS (TO BE SUMMED IN SEPERATLY ADOPTIVE MOTHER / FATHER) Name: Date: Sex: Occupation Date of birth: Blood group Height (cm) Weight (kg) HISTORY OF ILLNESS IN THE FAMILY Diabetes: Blood pressure: T.B. Asthma: Epilepsy Mental illness PERSONAL HISTORY Previous illness - Accident: If yes (Specify) Surgery Disease Emotional Health: D Habits: Alcohol Smoking Tobacco Nature of Job: Drugs Any other I. General Examinations -Colour __________ Dedema _________ II. Cardio Vascular System - Breathlessness Palpitations Chest pains Findings Heart Sound Murmur III. Respiration System: Symptoms - Cough Chest pains Breathlessness Findings - Foreign sounds IV. Renal System - Urinal complaints V. Menstruation - Any menstrual problem (Especially irregular bleeding) VI. Other - Herina If yes (specify) Hydrocel VII Mental Condition - Fits Migraine Anxiety state Depressive Affective disorder VIII Skin Problems Any other (specify) Leprosy Leucoderma IX Any medication at present long term / short term - (specify) problem. X. Relevant Investigation: Notes of Examination physician regarding current health status of applicant: Signature of the Physician Passport size Qualification photograph Reg. No. Note: This form is for both male and female applicants. Please write NA when not applicable. WOMEN DEVELOPMENT AND CHILD WELFARE DEPARTMENT :A.P.: HYDERABAD. B DECLARATION OF WILLINGNESS TO ADOPT This is to state that we the undersigned adoptive parents Mr.________________________ and Mrs. ________________________ both residing at ________________________________________________ _____________________________________________________________ are willing to adopt ________________________DOB ________________ from ___________________. We are willing to care for _______________ _____________________ and raise adopted boy / girl as our own son / daughter and to provide all the necessities required for his healthy and wholesome growth and development in to an adult. Adoptive Mother: Adoptive Father: Place: Date: LIST OF DOCUMENTS 1. Marriage Certificate / Wedding Card / Wedding Photo 1+2 Copies 2. Medical Fitness Certificate adoptive parents 1 + 2 Copies (Issued by Civil Surgeon/Asst. Civil Surgeon) 3. Current Photograph of adoptive parents (Post card Size) (Joint photos) 2 copies 4. Employment Certificate 1 +2 copies 5. Salary Certificate 1 + 2 copies 6. Infertility Certificate (Gynecologist) 1 + 2 copies 7. Declaration of willingness to adopt 3 copies 8. Consent letter 3 copies 9. Property documents 3 copies 10. Passport size photos of adoptive parents 2 copies each CONSENT LETTER I ____________________________ W/o _____________________ do hereby give my consent for the said proposal of adoption of Baby / Master _________________________. I further state that I am willing to be the mother of the said child proposed to be adopted by my husband. (Proposed Adoptive Mother)
