Adult Adopted Person Forms - The Cradle

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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 161b (rev. 01/2000) Printed by Authority of the State of Illinois P.O. #145083 3M 9/04 IL482-1015
Illinois Department of Public Health ADOPTED PERSON REGISTRATION IDENTIFICATION (Enter all known information.) I, ________________________________________________________, state the following: (present name) (first) (middle) (last) Adoptive name _____________________________________________________________ (first) (middle) (last) <strong>Adopted</strong> person’s birth name (if known)____________________________________________ Race _________ (first) (middle) (last) Date of birth _____________ Sex _____ Hospital (if known) ___________________________________ City and state of birth ________________________________________________________ Name of adoptive father ______________________________________________ Race _________ (if applicable) (first) (middle) (last) Name of adoptive mother _____________________________________________ Race _________ (if applicable) (first) (middle) (maiden) (last) I was adopted through________________________________________________________ (name of agency) (city and state of agency) I was adopted privately________________(state “yes” if known) I was adopted in____________________________________________ (city and state) _______________ (approximate date) Other identifying information___________________________________________________ __________________________________________________________________________ Name of birth mother_________________________________________________ (if known) (first) (middle) (maiden) (last) Name of birth father _________________________________________________ (if known) (first) (middle) (last) Race _________ Race _________ Provide name(s) at birth and ages of siblings(s) having a common birth parent with adopted person (if known). If more than one sibling, please give information requested below on reverse side of this form. __________________________________________________________________________ (first) (middle) (last) Date of birth__________________________________ Sex__________ Race _________ (or approximate age) City and state of birth ________________________________________________________ Name(s) of common birth parent(s) _______________________________________________ Race _________ (first) (middle) (last) _______________________________________________ (first) (middle) (last) Race _________ (Please note that (i) you must be at least 21 to register and (ii) if you were not born in Illinois, then you must submit a certified copy of your birth certificate.) _________________________________ (date) _________________________________ (signature of adopted person) _________________________________ (printed or typed name of adopted person) Illinois Department of Public Health, Division of Vital Records, 605 W. Jefferson St., Springfield, IL 62702-5097
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 and 22: This application is Illinois Depart
Page 23: 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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