Family Chronicle Registration Form

Families can utilize CHS’s Adoption Chronicles production services to create video interviews featuring details about the family’s life, home, and personalities. These Family Chronicles can be used by social work teams to find matches for waiting children and birth mothers. These videos can also be used to share information about a foster family with a child entering a new placement to alleviate transition issues.

* Required Fields

Select:	We are an Adoptive (Waiting) Family We are willing to travel to a filming location (may be 1-2 hours away) We prefer to be filmed closer to our hometown We would like to have our video features on the CHS/Adoption Chronicles website and receive DVDs (Cost: $300 per family - includes 10 DVDs) (* Select at least one)
Names:	*
Address 1:	*
Address 2:
City:	*
State:	Select Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federal States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming AA (Military) AE (Military) AP (Military) *
Zip Code:	*
County:	*
Email Address:	*
Phone:	*
Licensing Agency:	*
Case Number:
Social Worker:	*
Email Address:	*
Child Preference:
Age Group:	*
Sibling Group:	*
Gender:	*
Ethnicity:	*
Please provide a short paragraph describing yourself and your family. Tell us about the child/children you hope to adopt and your interests. This will go with your photo representing you on the website. *
We prefer to be contacted via: * Email Phone Mail