Inquiry Form

Inquiring About:

AdoptionFoster Care

Parent #1 First Name:

Parent #1 Last Name:

Parent #1 Date of Birth:

Calendar

Parent #2 First Name:

Parent #2 Last Name:

Parent #2 Date of Birth:

Calendar

Other Names(maiden, etc.):

Street Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Work Phone (Parent #1):

Work Phone (Parent #2):

Email Address:

Optional Information:

Where did you hear about CSB's Foster Care & Adoption Program? Radio Ad/ProgramTV Ad/Program
Newspaper Ad/StoryOther Foster Parent/Adoptive Agency
PosterBillboard
InternetChurch Flier
Agency EmployeeFair/Booth
Heart GalleryFriend
OAPLDirect Mail Postcard
Informational PamphletsPhone Book
SelfTransit/Bus

Other:

Ethnicity/Race (optional):

Comments:

If you have additional questions, please feel free to call the number below or send e-mail to the SCCS staff.
Summit County Children Services
Telephone: 330.379.1990
Fax: 330.379.1924
Email: inquiry@summitkids.org