*Proposed full name of child:

*Date of birth or approximate age of child:

*Adoptive parent / parents name:

*Address in the U.S.:

*Home telephone number:

*Email address for shipment notification:

*Country adopting from:

Any known allergies of child:

Any known major health problems:

Current medications child is taking:

Approximate dates of travel:

How did you hear about the medical Kit?