Susan Garner Eisenman
Attorney and Counselor at Law

Registration Form If you are interested in being placed on our waiting list, please print and complete the following information and send it to our office along with a check or money order for $50 to cover administrative fees. Names: ______________________________________________________ Address: _____________________________________________________               ______________________________________________________ Phone Number: ________________________________________________ Marital Status: _________________________________________________ Date/Place of Marriage (if applicable): _______________________________ Occupations: __________________________________________________ Education: ____________________________________________________ Hobbies: _____________________________________________________ Race: ________________________________________________________ Religion: ______________________________________________________   Please circle one: Do you have other children in the home: Adopted?     yes       no                          Biological?         yes       no Will you consider an infant of an unidentified birthfather?                 yes       no Will you consider an infant of limited family medical information?      yes      no   Unacceptable biological background information: ________________________ _____________________________________________________________   Are you willing to: Share letters and pictures with birthmother/father?           yes       no      maybe Meet on non-identified basis with birthmother/father?      yes       no      maybe    Meet on an identified basis with birthmother/father?         yes       no      maybe Would you consider: A child of black or bi-racial heritage?                              yes       no      maybe A child of Asian or Indian heritage?                                 yes       no      maybe A child of Caucasian heritage only?                                 yes       no      maybe A child of either sex?                                                      yes       no      maybe Would you be willing to attend educational adoption seminars presented by this office?                     yes       no      maybe What adoption education have you already received? ____________________________________________________________ Are you working with other adoption resources?             yes       no If yes, please indicate other sources  _________________________________ Do you have a completed home study?                            yes       no If yes, please indicate date and source ________________________________

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