REGISTRATION OF INTEREST
Confidential
Registration of Interest
Restricted
PLYMOUTH CITY COUNCIL
YOUR BASIC DETAILS
Name and Contact Details
1st Applicant
2nd Applicant
Title
Family Name
Previous family name
(if applicable)
Forenames
Other names you are known by
Date of birth
Place of birth
Day Telephone *
Evening Telephone*
Mobile Telephone*
Email address*
Current Address
Details
House Name/Number
Street
Town
Postcode
Local authority area you live
What date did you move to this
address – month and year.
Is this your permanent place of
residence?
(If not please give details)
If this is rented accommodation is
your Landlord amendable to
children living at the property?
REGISTRATION OF INTEREST
Page 2 of 18
PLYMOUTH CITY COUNCIL
RESIDENCE
Is your main home currently in the UK?
If not, state where your main home is
How long have you been living in the UK?
If you are a non-UK passport holder, state country
of issue
If you are a non-UK passport holder or European
Economic Area (EEA) citizen, do you have
permanent residency in the UK?
If not, how long have you lived in the UK?
If you are a non-UK and non-EEA citizen, do you
have indefinite leave to remain in the UK?
If you have lived at your current address for less than 10 years, please give previous
addresses
(if additional addresses, please complete on a separate sheet of paper)
1st Applicant
Previous Address
From
To
From
To
2nd Applicant
Previous Address
REGISTRATION OF INTEREST
Page 3 of 18
PLYMOUTH CITY COUNCIL
Identity
1st applicant
2nd applicant
Gender
Nationality
Ethnic Origin
Primary Language spoken in
the home
Other languages spoken in
the home
Do you consider yourself to YES
have a disability (please circle
relevant one)
NO
YES
NO
Do you need an interpreter? YES
NO
YES
NO
Religious persuasion or faith
group
Practising or non-practising
Have you ever been convicted or cautioned for a criminal offence?
Any conviction or caution considered to be “spent” under The Rehabilitation of Offenders Act 1974 must be disclosed. If you have never been
cautioned or been arrested for an offence please put never.
You will be asked to complete a full DBS check in Stage 1 of the process, but we do need to know now of anything that might come up.
Date
Offence
Penalty
1ST Applicant
2ND Applicant
Have you ever had a county court judgement made against you or have you ever been declared
bankrupt?
1ST Applicant
Yes
No
If Yes please give details:
2ND Applicant
Yes
No
If Yes please give details:
REGISTRATION OF INTEREST
Page 4 of 18
PLYMOUTH CITY COUNCIL
Current Driving Licence (please circle relevant one)
Do you have a current driving licence
Yes
No
Do you have regular use of a car
yes
no
OCCUPATION
Current Employment
1ST APPLICANT
2ND APPLICANT
Current employer and address (if any)
Current hours of work
Proposed hours of work following
placement of child
Have you ever worked with children or vulnerable adults? If so, please list the employers’ name and
addresses below.
REGISTRATION OF INTEREST
Page 5 of 18
PLYMOUTH CITY COUNCIL
YOUR RELATIONSHIPS
Partnership Status
1ST Applicant
2ND Applicant
If you are married, give date
and place of marriage
If you have a registered civil
partnership give date and
place of registration
If you live with a partner,
date on which you set up
household together
If you are separated, or
divorced, or have dissolved a
civil partnership, give the
date and name of your
previous partner/s
If Decree Nisi has been
granted, please insert date
If you previously set up
household with a partner,
give date when this ended
and name of partner
Have you ever parented
children with previous
partners? If so, please give
details
REGISTRATION OF INTEREST
Page 6 of 18
PLYMOUTH CITY COUNCIL
Briefly outline the qualities in your relationship with each other, and how you feel you work as a
couple? What are your strengths and vulnerabilities as you see them?
REGISTRATION OF INTEREST
Page 7 of 18
PLYMOUTH CITY COUNCIL
YOUR HEALTH
Health Considerations
You will be undertaking a full medical in Stage 1, however we need to check some basic health facts at this
point in case we need medical advisors advice in advance of accepting your Registration of Interest form.
Please be as honest and open as you can be.
1st Applicant
2ND Applicant
How would you describe your
general health?
How would you describe your
general lifestyle and activity levels?
Are you a smoker? If so how many
per day and do you have any plans
to stop? If you were previously a
smoker when did you stop
smoking? (See Information Pack)
Do you drink alcohol, and if so how
much and when?
Do you have any difficulties around
your weight (over or under)?
Do you, or have you in the past
ever had any depressive or mental
illness. If yes, briefly state what and
when and whether you are still
using medication. (Don’t worry if you
have had depression in the past, we
fully expect most people to have had
something at some point)
Do you have any specific health
conditions? When did you last
receive treatment?
Are you on any other medication
for specific health conditions?
REGISTRATION OF INTEREST
Page 8 of 18
PLYMOUTH CITY COUNCIL
Any other comments you would like to make about your health status?
REGISTRATION OF INTEREST
Page 9 of 18
PLYMOUTH CITY COUNCIL
WHERE YOU LIVE AND WHO YOU LIVE WITH
Describe your accommodation, paying particular attention to the way that it is suitable for
caring for a child.
Include how many rooms you have, confirm that the adopted child will have their own bedroom, is there a
safe outside garden/space available, is the tenancy/mortgage secure, do you have any plans for major
refurbishment in the near future, or plans to move? If you live on a working farm or similar, please confirm
that there are suitable, child friendly safety measures in place.
Briefly describe the neighbourhood and community where you live and the way in which it is suitable to care
for a child.
REGISTRATION OF INTEREST
Page 10 of 18
PLYMOUTH CITY COUNCIL
WHO ELSE LIVES IN YOUR HOUSEHOLD?
Children (under 18) within the current household
Name
Gender
DOB
Relationship to applicant
Adults – including grown up children
Name
Gender
DOB
Relationship to applicant
Are there other adults (not living in your household) who may have responsibility on a
regular basis for the care of any child/ren placed with you?
Name
REGISTRATION OF INTEREST
Gender
DOB
Relationship to applicant(s)
Page 11 of 18
PLYMOUTH CITY COUNCIL
Do you have any children (under 18) from a current or previous partnership living
elsewhere?
Name
Gender
DoB
Ethnicity
Relationship to
Applicant(s)
Address
Relationship to
applicant(s)
Address
Do you have any adult children living elsewhere?
Name
Gender
DoB
Ethnicity
What do these additional members of your household think about your plans for adoption?
REGISTRATION OF INTEREST
Page 12 of 18
PLYMOUTH CITY COUNCIL
Have you been involved in any family court proceedings or in any proceedings about children and/or
family? Yes No
If YES, give details of the date, name of court, type of order made and the name of the children
concerned
Date
Court
Court Order Made Name of children
(if applicable)
YOUR FINANCES
You will be asked to complete a more comprehensive finance statement in Stage 1 however for the
purposes of this document please can you respond to the following questions:
1ST Applicant
2ND Applicant
How would you describe
your current financial
situation?
Do you have many
outstanding debts?
REGISTRATION OF INTEREST
Page 13 of 18
PLYMOUTH CITY COUNCIL
ANY RECENT LOSSES
Starting on the adoption process is an emotionally trying time, and you need to be as
emotionally robust as you can be. If you have had any recent losses, or significant life events
that have caused you emotional upset, you may find that these emotional responses are
retriggered when you start talking deeply around subjects such as children’s experiences or grief
and loss. Please mention below any significant losses or life events which you feel may be
relevant.
REGISTRATION OF INTEREST
Page 14 of 18
PLYMOUTH CITY COUNCIL
YOUR EXPERIENCE WITH CHILDREN
Briefly outline your current experience of caring for children, how often have you done this and
how recently? What is the age range of the children you have experience of? What kind of
activities do you enjoy with the children you care for…do they come and stay at your home? If
you haven’t had much experience caring for children, how do you propose to get this?
1ST Applicant:
2ND Applicant:
YOUR SUPPORT NETWORK
Briefly outline who would be available to support you, locality of close friends, family, work
colleagues, people who you can support you both practically and emotionally should you need
to. Are these people aware of your plans for adoption yet? If yes what has been their general
reaction?
1ST Applicant:
2ND Applicant:
REGISTRATION OF INTEREST
Page 15 of 18
PLYMOUTH CITY COUNCIL
PETS
Please describe below the pets you have currently in the household. Say how many you have,
their ages, how long you have had them, and how they are with children (if known). If you have
dogs, please answer additional questions below;
Dogs
Dog’s Name, gender, age, breed and size
Is it a Pet, Working Dog, Breeding Dog or Guard
Dog? If Guard Dog we will need to see an
appropriate registration certificate.
If rescued/rehomed, what were the circumstances
and how much is known of your dog’s history?
If your dog had been previously maltreated, what
impact has this had on your dog’s behaviour
Is your dog neutered /spayed?
Where is the dog allowed within the house?
Is there anywhere that is exclusive to the dog (i.e.
kennel, garden, cage, bed)
Where does it stay during the day and sleep at
night?
Please describe the temperament of the dog (tick all that apply)
Boisterous
Usually Placid
Playful
Docile
Nervous
Submissive
Disobedient
Protective of property
Obedient
Possessive –over
Protective (people or
property)
Has the dog ever bitten, snapped or snarled at
anyone? Please give details
Does your dog get on with other dogs?
Does the dog worry people in public or when
visiting the home? If so how is this managed
How are you planning to introduce the dog to a
child, what contingencies will you put in place if
either child or dog struggles with the relationship?
REGISTRATION OF INTEREST
Page 16 of 18
PLYMOUTH CITY COUNCIL
MOTIVATION TO ADOPT
Explain below your reasons for wanting to adopt right now? What has brought you to adoption,
and what do you think you can offer as adoptive parents?
Date of last/most recent treatment for
infertility (if applicable)
What sort of children do you have in mind? Age range? Gender? Ethnicity ? One or Two or Three?
Are you able (for example) able to consider children with special needs or disabilities? Please outline below if
you have any particular thoughts on the subject – you may not yet and that is fine.
REGISTRATION OF INTEREST
Page 17 of 18
PLYMOUTH CITY COUNCIL
I certify that, to the best of my knowledge and belief, the details supplied in this application are
correct. I understand that the agency may seek verification of any of the facts supplied. I understand
that if any of this information is found to be false or misleading, this may result in the agency rejecting
my application. I understand that it is important not to withhold any information about factors that
may influence my capacity to care for a child. If I have any uncertainty about this then I will discuss
the details with an agency Social Worker during the process.
I give my consent to the agency asking for information (written or verbal) from individuals, agencies
or organisations identified by me to the agency in support of this application. I understand that any
information obtained will only be used in processing my application. This includes a written report
from my registered medical practitioner about my health. I understand that I may not be entitled to
see some of this information where it has been supplied confidentially.
I understand that the agency may ask me to supply further information in order to assess my
application.
I understand that any information supplied by me in respect of this application may be held and/or
processed in an electronic form and is subject to the relevant provisions in the Data Protection Act
1998 and other relevant statutes. I understand that any information supplied will form part of the
agency’s case record in respect of my application.
I understand that this form is the property of the agency to whom I have applied. I agree not to copy
this document (other than for my own personal records) or disclose its contents in full or in part, to
any other person, agency or authority without the agency’s permission.
Name of 1st Applicant
Signature 1st Applicant
Date:
Name of 2nd Applicant
Signature of 2nd Applicant
Date:
Can you please ensure that you will be contactable within the first week of submitting your
Registration of Interest form, should we need to clarify any details with you.
Please also insert below the most convenient time to contact you and your preferred contact
method.
AM
Home Number / Mobile
PM
Home Number / Mobile
PLEASE RETURN COMPLETED FORM TO:
Adoption Service
Children’s Social Care
Midland House
Notte Street
Plymouth
PL1 2EJ
REGISTRATION OF INTEREST
Page 18 of 18