11.) Application and Undertaking For Adoptive Applicants Template As of 09.12.2022

Republic of the Philippines
NATIONAL AUTHORITY FOR CHILD CARE

2 Chicago Street corner Ermin Garcia Street, Barangay Pinagkaisahan,
Cubao Quezon City, 1111 Philippines
NACC Domestic Adoption Application Form No. 1
APPLICATION AND UNDERTAKING FORM FOR ADOPTIVE APPLICANT/S
Part 1: Information and personal data of applicant/s
Male Applicant Female Applicant

Full Name
Age
Date of Birth
Place of Birth
Religion
Nationality/Citizenship
Residence Address
Home Phone Number
Mobile Number
E-mail Address
Civil Status
If married, date and place of marriage
Date of previous marriage, if any, and
manner of termination
Educational Attainment
Present Occupation
Monthly Income
Name of Employer/Agency
Business Address
Business Phone Number
Other Income Sources (specify)
Amount of Savings
Monthly Expenses
Insurance
Real Properties
Membership in Association/Clubs
Hobbies/Interest
Recreational Activities
Household Composition: (Nuclear family and other individuals living with applicant/s in
present address)
Name Relation to Date Age Sex Educational Disability/

Applicants of Attainment Sickness,
Birth specify
1.
2.
3.
4.
How did you learn about adoption?

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Motivation to adopt:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Page 1 of 3
Our/My experience in caring for children:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Our/My experience of being cared for by our/my parents are:

______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Child Preference, if applicable
Sex & age of the child: _____________________________

Siblings or twins (please specify number _____________________________
of siblings – i.e sibling group of 2 or 3 _____________________________
Health condition
_____ Healthy
_____ Manageable medical condition
_____ serious medical condition
Development condition
_____ No developmental needs
_____ slight developmental needs
_____ major developmental needs
Physical condition
_____ No physical deformities
_____ mild physical deformities
_____ major physical deformities
Child background
_____ no known background
_____ born out of incest
_____ born out of rape
_____ with history of abuse
_____ (specify):____________________
other (specify):
________________________________
Parental Background
_____ no known information
_____ with known information
_____ with history of drug use
_____ with history of mental illness
_____ with history of abuse
(specify):____________________
**Please attach latest picture of the applicant/s and his/her immediate family members and their
home (3X5 inch taken within the last six (6) months from the date of submission of application).
Page 2 of 3
Part 2. Undertaking
Please tick off.

____ That we/I are/am qualified to be adoptive parents;
____ That we/I have the capacity to act and to assume all rights and responsibilities of
parents;
____ That we/I have not been convicted of a crime involving moral turpitude;
____ That we/I have good moral character and can model the same to the adoptive child:
____ That we/I can provide support and proper physical, social and psychological care to all
of our children including the child/children we intend to adopt;
____ We/I agree to uphold the basic rights of the child under our/my national laws, and the
Child and Youth Welfare Code of the Philippines (PD 603) as well as the UN Convention
on the Rights of the Child;
____ That we/I agree to abide by the Guidelines and/or Implementing Rules and Regulations
promulgated by the National Authority for Child Care; and
____ That we/I did not in any manner try to induce, coerce or influence the biological
parents/guardians/child caring or placing agency in favor of this application.
_____________________________ _____________________________
Name and signature of Applicant Name and signature of Applicant
Date signed: ___________________ Date signed: ___________________
SUBSCRIBED AND SWORN TO BEFORE ME, a notary public in and for ____________________
this ______ day of _______________ 20____ by the following, who exhibited to me their
respective government issued ID, as follows:
Name Government-issued ID Date and Place Issued
1.
2.
This instrument consists of ____ pages including this page where the notarial seal is
affixed.
Doc. No. ______;
Page No. ______; NOTARY PUBLIC
Book No. ______;
Series of ______.
Page 3 of 3

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Republic of the Philippines

NATIONAL AUTHORITY FOR CHILD CARE

NACC Domestic Adoption Application Form No. 1

APPLICATION AND UNDERTAKING FORM FOR ADOPTIVE APPLICANT/S

Part 1: Information and personal data of applicant/s

Male Applicant Female Applicant

Name Relation to Date Age Sex Educational Disability/

How did you learn about adoption?

Our/My experience of being cared for by our/my parents are:

Child Preference, if applicable

Sex & age of the child: _____________________________

Please tick off.

Date signed: _ Date signed: _

Name Government-issued ID Date and Place Issued

Doc. No. ______;

Page No. ______; NOTARY PUBLIC

Book No. ______;

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