Adult Adopted Person Forms - The Cradle

2049 Ridge Avenue, Evanston, IL 60201 847-475-5800
Information Exchange Authorization
I/We, _________________________________________, state that I/we am the person who completed the Registration Identification;
that I am ______ years of age; that I hereby authorize The Cradle to give the following person(s): (check as applicable)
adopted person birthmother birthfather birth sibling adopted adoptive parent(s) other birth relative(s)
adult child of a deceased adopted person surviving spouse of a deceased adopted person all eligible relatives
the following information:
(please check the information authorized for exchange)
Contact me first before releasing identifying information.
Only my name and last known address can be released.
A copy of the completed medical questionnaire can be released.
I am fully aware that I can only be supplied with any information about the individual(s) who has duly executed an Information
Exchange Authorization for the information which authorization has not been revoked.
My contact information is as follows:
My Name or Name of Person through Whom I May Be Contacted
Phone
Street Address
City, State, Zip Code
E-mail
Signature
Date
*adopted person must be 21 years of age or older to Register.
Please be sure to keep The Cradle updated about your contact information.
State of ______________________________ County of ________________________________
I, a Notary Public, in and for this county, in the state aforesaid, do hereby certify that
is personally known to me to be the same
person whose name is signed to the foregoing Information Exchange Authorization, appeared before me in person and acknowledged
that she/he signed such certificate as her/his free and voluntary act and that the statements in such authorization are true.
Given under my hand and notarial seal this _____ day of ___________________, ________.
(Seal)
______________________________________________
Signature
09/09 x:/Materials/Post Adoption/Forms/infoex.doc