Connections UnitingCare Adoption and Permanent Care

Enquiry Form

Where did you hear about the Connections Permanent Care program?
Personal information:
Your surname:
Your given name/s:
Your age:
Your partner's surname:
Your partner's given name/s:
Your partner's age:
Do you have Children?
Yes No
Contact details and tick your preferred method of communication.
Address:
Locality:
	Post Code:	State:
		VIC ACT NSW NT QLD TAS SA WA Other
Home phone:
Work phone:
Mobile phone:
Email:
Preferred method of communication:
Home phone Work phone Mobile phone Email
Your occupation:
Your partner's occupation:
Relationship (please tick):
Single Married Defacto
Length of relationship:
Please note that in order to be assessed for the Permanent Care Program you would need to show proof of the relationship being at least 2 years long.
Have you undergone fertility treatment?
Yes No
Please note that in order to be assessed for the Permanent Care Program you would needed to have ceased fertility treatment for at least 6 months.
Is at least one partner an Australian citizen?
Yes No
Do you wish to be invited to the next information session?
Yes No
Comments
Security Code

PRIVACY POLICY: Connections acknowledges and respects the privacy of all individuals. The agency will comply with the Privacy Principles contained in the Privacy Amendment (Private Sector) Act 2000 (Commonwealth), the Information Privacy Act 2000 (Vic) and the Health Records Act 2001 (Vic). You can ask to see our Privacy Policy. If you have any questions call 03 9271 0800 and ask to speak to the Community Relations Department of Connections.