DSWD-CYWP

Form No. 001-A

1

APPENDIX E-

Republic of the Philippines

Autonomous Region in Muslim Mindanao
Department of Social welfare and development
MAGUINDANAO BRANCH
ORC Compound, Cotabato City
APPLICATION FORM
FOR RELATIVE/INDEPENDENT ADOPTION
1.IDENTIFYING DATA:
HUSBAND
: ______________________

Legal Name
__________________
Age/Date of Birth
:_______________________
__________________
Place of Birth
:_______________________
__________________
Citizenship
:_______________________
__________________
Home Address
:_______________________
__________________
Home Phone
:_______________________
__________________
Religion
:_______________________
__________________
Highest Educl. Attainment
:_______________________
__________________
Marital Status
:_______________________
__________________
Date & Place of Marriage
:_______________________
__________________
Date of Previous Marriage
:_______________________
__________________
Manner by which Marriage was
:
terminated, if applicable
:_______________________
__________________
Military service: State Branch & No. :
Of years
:_______________________
__________________
Membership in Organization
:_______________________
__________________
2.ECONOMIC DATA:
Occupation
__________________
Employer
__________________
Business Address & Tel.No.
__________________

:_______________________
:_______________________
:_______________________

WIFE

Salary/Month
__________________
Income other than Salary
__________________
Savings
__________________
Insurance
__________________
Loans/Debts
__________________

:_______________________
:_______________________
:_______________________
:_______________________
:_______________________

3. HOUSEHOLD MEMBERS:
a) List all individuals living with you in present address:
Name
Relative to Head
Age Sex
OccuSickness/
Attnmt.
Handicap
_______________
______________
___
___
__________
_______
_______________
______________
___
___
__________
_______
_______________
______________
___
___
__________
_______
_______________
______________
___
___
__________
_______

b) List of Children of either

Name
Age
Occupation
Attnmt.
_______________
___
___
_______________
___
___
_______________
___
___
_______________
___
___

Eductl
Pation
_______
______
_______
______

spouse living away from you:

Sex
Where/With
Eductl
Whom Living
________________
________________
________________
________________

_________
_________
_________
_________

___________
___________
___________
___________

4. What are your reasons for wanting to adopt the child?

_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
5. What were the circumstances which led to your custody of the child?
Please also state date when you got actual custody of the child.
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_

6 .Do you know the childs biological parents? If so, how are you related?
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
7. If the child you are adopting is a rerlative, what are your feelings about
the childs knowing her biological parents?
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
8. Do you have any expectation of the child you want to adopt? If so, what
are these?
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
9. If the child does not meet your expectations, what will you do?
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
10. What are your experiences in caring for children?
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
11. How were you cared by your parents?
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
12. What arrangements for alternative care do you have for the child, if at
times you cannot attend to her/his needs?

_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
13. What is your reaction if a social worker interviews your children,
relatives, friends and employer?
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
14. What is your opinion on the supervision of the Department of Social
Welfare development?
_____________________________________________________________________________
_
_____________________________________________________________________________
_
_____________________________________________________________________________
_
15. Who may be contacted for more information?
NAME
ADDRESS/TELEPHONE NO.
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________

____________________________________
____________________________________
Signature of Male Applicant
Applicant
_____________________
Date

Signature of Female

_______________________
Date