Adult Adopted Person Forms - The Cradle

2049 Ridge Avenue, Evanston, IL 60201 847-475-5800
Client Information
Your Name (First, Middle, Last) _______________________________________________________________________
Are you a/an:
Adult Adopted Person
Birth Father
Adoptive Parent
Birth Sibling Adopted
Adult descendant of Adopted Person
Surviving relative of deceased Birth Parent
Birth Mother
Other
Name(s) of Adoptive Parents at the time of the adoption:
Adopted Person’s date of birth: ___________________
Birth Mother’s date of birth: ______________________
Your social security number: _____________________
OR
Name(s) of Birth Parents at the time of the adoption:
_____________________________________________
Your home phone number: _______________________
Your work phone number: _______________________
Your cell phone number: ________________________
Your Email address: ___________________________
Your Home Address:
______________________________________________________________________________________________
______________________________________________________________________________________________
Special mailing instructions (i.e. plain envelope for privacy, or a trusted friend or relative who will be your contact person):
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Signature: ________________________________________________________
Date: ______________________
Parental Permission (if applicable):
I/We are aware that an adopted person under 21 years of age must have the written consent of the adoptive parent(s) in
order to receive non-identifying information. I/We do hereby give my/our permission for __________________________,
who is 18-20 years of age, to receive non-identifying information. Attached is a copy of my/our photo ID(s).
Signature:
Signature:
Date:
Date:
Would you like to receive:
Post Adoption Workshop/Support Group Notices (Chicagoland Only)
Yes
No
General Cradle Newsletter
Yes
No
Cradle Events
Yes
No
09/09 x:/Materials/Post Adoption/Forms/Client Information.doc