First Name

Last Name

Spouse's First Name (if applicable)

Email Address

Phone Number

Street Address

City

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Zip

Country United States Canada Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curaçao Cyprus Czech Republic Côte d’Ivoire Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong S.A.R., China Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao S.A.R., China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Réunion Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican Venezuela Viet Nam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe

Child's Chinese Name If unknown, write "unknown."

Child's Advocacy Name (if known)

Name You've Given Your Child

Child's Date of Birth [YYYY-MM-DD]

Child's Sex Male Female Prefer not to disclose

Care Center(s) Where Your Child Received Care Luoyang (Maria's Big House of Hope)BeijingJiaozuoNanjing NanyangXinyang Zhengzhou Uknown

Do you have more than one child who was cared for at the Care Centers? yes no

Child #2's Chinese Name If unknown, write "unknown."

Child #2's Advocacy Name (if known)

Name You've Given Child #2

Child #2's Date of Birth [YYYY-MM-DD]

Child #2's Sex Male Female Prefer not to disclose

Care Center(s) Where Child #2 Received Care Luoyang (Maria's Big House of Hope)BeijingJiaozuoNanjingNanyangXinyangZhengzhouUnknown

Do you have more than two children who were cared for at the Care Centers? yes no

Child #3's Chinese Name If unknown, write "unknown."

Child #3's Advocacy Name (if known)

Name You've Given Child #3

Child #3's Date of Birth [YYYY-MM-DD]

Child #3's Sex Male Female Prefer not to disclose

Care Center(s) Where Child #3 Received Care Luoyang (Maria's Big House of Hope)BeijingJiaozuoNanjingNanyangXinyangZhengzhouUnknown

Do you have more than three children who were cared for at the Care Centers? yes no

Child #4's Chinese Name If unknown, write "unknown."

Child #4's Advocacy Name (if known)

Name You've Given Child #4

Child #4's Date of Birth [YYYY-MM-DD]

Child #4's Sex Male Female Prefer not to disclose

Care Center(s) Where Child #4 Received Care Luoyang (Maria's Big House of Hope)BeijingJiaozuoNanjingNanyangXinyangZhengzhouUnknown

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