ADOPTEE SUBMISSION: BASIC INFORMATION
Last Name First Name MI
Mailing Address (Optional)
City State Zip Phone#
Email Address (Required if no mailing address given)
I am a: Select one of the following Female Adoptee Male Adoptee Member of Adoptive Family Friend of Adoptee Professional Researcher Private Investigator Other (please specify) Searching for: Please select one of the following ANY member of Birthfamily Birth Mother Birth Father Birth Sibling Other
I am searching because...
Things I would like to say to the person I am searching for:
Vital Information
Current Name of Adoptee
Other Name(s) Adoptee has used
Name at Birth (if known)
Other names used/given
Birth Date 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month January February March April May June July August September October November December Year: Time am pm
City of Birth or Region State
Name of Hospital
THE FOLLOWING INFORMATION IS "OPTIONAL," (AND WE DO SUGGEST THE POSSIBILITY OF WITHOLDING CERTAIN VITAL INFORMATION FOR VERIFICATION PURPOSES) HOWEVER THE MORE INFORMATION YOU PROVIDE, THE BETTER CHANCES YOU HAVE OF A SUCCESSFUL SEARCH!
Adoptive Parent's Name(s)
City of Residence
Adoption Agency Name
City, County, and State where adoption took place
Name of Delivering Doctor or Nurse Midwife
My birth is known to be a single birth multiple birth
Other information known about the birth:
Birth Mother's Name
Other names Birth Mother has gone by
Address at Birth
Last Known Address
Occupation at Birth
Current or Potential Occupation
Other family members of Birth Mother
Other known or suspected information about Birth Mother
Birth Father's Name
Address
Other family members of Birth Father
Other known or suspected information about Birth Father
Other known information about any other member of Birth Family
ADDITIONAL "OPTIONAL" INFORMATION (- NOT REQUIRED)
These are a few "just to let someone know" items that you may wish to include...
Adoptee's highest level of education Select one Grade School High School Technical or Professional School Military Training Some College College, Associate Degree College, Bachelor Degree College, Masters Degree College, Doctorate Level
Adoptee's Occupation
Marital Status Select one Single Single and loving it Married Separated Divorced Widowed
Number of Children
Achievements
Hobbies
Allergies
Medical Problems
Hair Color Eye Color
Height Weight Race
Identifying factors or traits
Thank you for your submission! Please note that the information given here will be posted in our registry as soon as possible. If you have any other information that you wish to be included in your registry posting that doesn't fit here, experience ANY difficulty with this form, or do not see your submission posted within 48 hours, PLEASE email me as soon as possible. This registry is here to help you, and we'll do everything we can to do so! adoptiongirl@cyberbabies.com
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