This is a _ New Entry Updated form    *                                                * Required

I am _ Adoptee Birth Mother Sibling to adoptee by adoption Adoptive Parent Friend of Adoptee Other - I will explain below Birth Sibling Birth Father Birth Family Relative Birth Grand Parent Adopted Family Member *          If answer is "other" - please explain in area below marked additional information.

First Name*                Middle Name           Last Name        *

Address  *

City     *                   State    _ AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA DC WV WI WV    *                        Zip

Phone   Area Code           Phone Number example 555-1234

E-mail Address:   *   Please check to make sure your email address is correct. Remember to update your record if your email changes.  If you do not have an email address - please enter another way to contact you - such as an alternate phone number - or type "none".  This helps us when a registry reunion occurs.

Adoptee Information

Name given at birth (include first and last name if you know the name you had before adoption)

Date of Birth:      Month  _ Jan Feb Mar April May June July Aug Sept Oct Nov Dec Unk Spring Summer Winter Fall *    Day  _ 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Unk *   Year  _ 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 Unk    *         Sex _ Male Female Unk *      Race   
*****Is Date of Birth Entered correctly?  *****
If you do not know the Month, Day or Year of birth or sex- please enter "unk" 
 
Birth Certificate Number (sometimes called a File Number) 
 

Place of Birth:    Hospital     City   State _ AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA DC WV WI WV unk

Doctor

Time of birth            Birth weight 

Birth Marks

Medical  Problems at birth

Adopted Name  

Adoptive Mother Name (include Maiden name)

Adoptive Father Name

Residence of Adoptive Parents at time of adoption   City             State  _ AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA DC WV WI WV

Adoption Agency

Adoption Attorney

Adopted Siblings that are in adopted family

Information of the Birth Mother at the time of adoption

Name used by birth mother at time of adoptee birth

Maiden name of birth mother

Birth Mother Date of Birth  Month  Jan Feb Mar April May June July Aug Sept Oct Nov Dec _ Unk        Day    1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 _ Unk     Year   _ 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 Unk      Age at time of adoptee birth        Race 

Place of  birth:      City                   State _ AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA DC WV WI WV

Height   Weight    Hair Color     Eye Color

Residence at time of adoptee birth   City      State AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA DC WV WI WV _

Marital Status  single married widowed divorced Unk _                Married to birth father        unk yes no _

Religion    Occupation  

Education

Maternity Home   If you do not know Maternity Home - type Unknown

Siblings of the Birth Mother

Parents of the Birth Mother

Birth Mother's Other birth children

Information of the Birth Father  at the time of adoption

Name             

Residence at time of the adoptee birth     City           State _ AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA DC WV WI WV

Birth Father Date of Birth     Month  _ Jan Feb Mar April May June July Aug Sept Oct Nov Dec      Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 _      Year _ 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 Unk

Age at time of adoptee's birth      Race

Place of birth   City             State _ AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA DC WV WI WV

Height   Weight    Hair Color   Eye Color

Education   Religion   Occupation

Marital Status  single married widowed divorced unk _                               Married to birth mother    unk yes no _

Birth Fathers Other birth children

Siblings of the birth father

Parents of the birth father

Additional Information: (include anything else that you might know/remember about the adoption
or birth)

If you use any of these programs - please give us your id - in case we need to contact you

ICQ Number:

AOL Instant Messenger Screen Name

Yahoo Messenger Screen Name

MSN Messenger Screen Name  

Did you remember to include your address, phone, etc? If your email changes that maybe the only other way we can contact you. -  don't miss out on a reunion. 

We have had several reunions and the email address are wrong or not working -  don't let this happen to you.

By submitting this form I agree that the registry has permission  to cross check the registry for any matches and advise me accordingly of any matches now or later.   I further release the registry of any responsibility /liability if a match is made.