Chosen Children's Charities, Inc. -- Adoption Data Questionaire

I am: _____ an Adoptee _____ a Birth/Biological Parent _____ an Adoptive Parent

Name: (Optional)________________________________________________________________________

Address: (Optional)_____________________________________________________________________
     -or-
Current Residence: Country___________  State______________ 
   
                   County____________  City_______________

Sex:      ___Male             ___Female 

Race:  ___Caucasion         ___African American     ___Hispanic American

       ___Oriental American ___American Indian      Other___________________________________

Date Of Birth (Optional): _______/_______/_______
          -or-
  Age: ___18-21 ___41-50
   
       ___22-30 ___51-60
         
       ___31-40 ___61+
       
       

                                             

Marital Status:    ___ Single     ___ Divorced   ___ Married    ___ Widowed

Household Annual Income: 
          ___ Below $10,000        ___ $40,001-60,000       ___ $175,001-200,000
          ___ $10,001-25,00        ___ $60,001-100,000      ___ $200,001-250,000
          ___ $25,001-40,000       ___ $100,001-175,000     ___ Above $250,000

Sources Of Income Other Than Salary:

  ___Annuities                  ___Interest/Dividends        ___Insurance
  
  
  ___Profit Sharing/Pension     ___Inheritance               Other__________________

Your Employment:                       Your Spouse's Employment:
     ___ Unemployed                              ___ Unemployed 
     ___ Housewife/Househusband                       ___ Housewife/Househusband 
     ___ Retired, at age ____                         ___ Retired, at age ____
     ___ Self-Employed                                ___ Self-Employed
     ___ Other-Employed                               ___ Other-Employed
            ___Salaried                                      ___Salaried
            ___Hourly                                        ___Hourly
            ___Supervisor/Manager                            ___Supervisor/Manager
            ___Executive/Officer                             ___Executive/Officer
            
            
Trade/Profession __________________________       Trade/Profession __________________________

Your Biological Children:      if any -- how many living in your home _____
Your Adopted Children:         if any -- how many living in your home _____

Your Home:Primary Residence:                      Secondary Residence:
     ___Own          ___ Rent/Lease               ___Own         ___Rent/Lease
     ___Apartment    ___ Condominium              ___Apartment   ___Condominium
     ___Single Family Home                        ___Single Family Home
     
     
     Other ________________________               Other _______________________


Automobile:    1. Own ___ Lease ___ Make ____________________

  
               2. Own ___ Lease ___ Make ____________________



Education:  High School:___Public
                        ___Private          
                        ___Parochial
                        ___Graduated 
                        ___Attended to grade ____

            College/University: ___State/Public
                                ___Private
                                ___Parochial
                              
                 ___Graduated with ___________________________ advanced degree
                 
                 ___Graduated with ___________________________ degree
                 
                 ___Attended for ______ terms


Religious Affiliation:   ___Christian  ___Jewish    _____________________ Other