Adult Adopted Person Forms - The Cradle

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REQUIRED DOCUMENTATION Adopted/Surrendered Person or Adoptive Parent or Legal Guardian of an adopted/surrendered person ❏ Appropriate Registration Identification form ❏ Adoption Registry Application form ❏ Photocopy of photo identification ❏ Information Exchange Authorization form OR ❏ Denial of Information Exchange Authorization form With one of the following: With $40.00 registration fee made payable to IDPH a. Completed Medical Questionnaire form b. $40.00 registration fee made payable to IDPH ❏ If born outside of ILLINOIS, certified copy of birth certificate ❏ If a legal guardian, certified copy of court ordered guardianship Birth Mother/Father ❏ Appropriate Registration Identification form ❏ Adoption Registry Application form ❏ Photocopy of photo identification ❏ Information Exchange Authorization form OR ❏ Denial of Information Exchange Authorization form With one of the following: With $40.00 registration fee made payable to IDPH a. Completed Medical Questionnaire form b. $40.00 registration fee made payable to IDPH Surviving Relative of a Deceased Birth Parent (birth parent’s non-surrendered child, sister or brother) ❏ Appropriate Registration Identification form ❏ Adoption Registry Application form ❏ Photocopy of photo identification ❏ Information Exchange Authorization form OR ❏ Denial of Information Exchange Authorization form With one of the following: With $40.00 registration fee made payable to IDPH a. Completed Medical Questionnaire form b. $40.00 registration fee made payable to IDPH ❏ Certified copy of birth and death certificate of birth parent ❏ Certified copy of your birth certificate Surviving Relative of a Deceased Adopted/Surrendered Person (adult child or spouse with a minor child) ❏ Appropriate Registration Identification form ❏ Adoption Registry Application form ❏ Photocopy of photo identification ❏ Information Exchange Authorization form OR ❏ Denial of Information Exchange Authorization form With one of the following: With $40.00 registration fee made payable to IDPH a. Completed Medical Questionnaire form b. $40.00 registration fee made payable to IDPH ❏ Certified copy of birth and death certificate of adopted/surrendered person ❏ Certified copy of the adopted/surrendered persons child’s birth certificate ❏ If spouse with minor child, certified copy of marriage certificate
Illinois Department of Public Health ILLINOIS ADOPTION REGISTRY APPLICATION Section C - Optional written statement This optional written statement is authorized for release as specified in Section C of the Adoption History Application. This statement is limited to the space (two pages) provided on this form and cannot include information that would identify any person other than the registrant submitting the statement. This written statement will be reviewed by registry staff to verify compliance with the law. Registry staff must remove prohibited identifying information or return the statement to the registrant for compliance. Please type, write clearly or print in dark blue or black ink. A lined and unlined page are provided for your convenience. Both pages may be used. _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ Illinois Department of Public Health, Division of Vital Records, 605 W. Jefferson St., Springfield, IL 62702-5097 VR 161a (rev. 01/2000) Printed by Authority of the State of Illinois P.O. #145083 3M 9/04 IL482-1015
Page 1 and 2: 2049 Ridge Avenue, Evanston, IL 602
Page 3 and 4: Reconnection From time to time, bir
Page 5 and 6: Fee Schedule Post Adoption Services
Page 7 and 8: 2049 Ridge Avenue, Evanston, IL 602
Page 9 and 10: Our mission is to benefit children
Page 11 and 12: Our mission is to benefit children
Page 13 and 14: Personal History & Biography Questi
Page 15 and 16: Writing “Your First Letter” 204
Page 17 and 18: With Authorization. Uses and disclo
Page 19 and 20: Children’s Adjustment to Adoption
Page 21: This application is Illinois Depart
Page 25 and 26: Illinois Department of Public Healt
Page 27 and 28: Illinois Department of Public Healt
Page 29 and 30: F. HORMONAL DISORDERS 1. Diabetes 2

Adult Adopted Person Forms - The Cradle

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