I am registering/registered as (check one) ___ an adult adopted or surrendered person; ___ a birth parent; ___ adoptive parent or legal guardian of an adopted or surrendered person; ___ a non-surrendered birth sibling as stated on the registration identification.

Section A. REGISTRANT INFORMATION

Name:

Today's date:

(first)

(middle)

(maiden)

(last)

Mailing address:

(street)

(city)

(state)

(zip code)

Sex:

SSN

     -       -

Phone:

(    )

This application is (check)

(male or female)

(OPTIONAL)

  a new registration

  an update to a prior registration

 to request and/or file medical information

Birth name of adopted

or surrendered person:

Sex:

(if known)

(first)

(middle)

(last)

(male or female)

Adoptive name of adopted or surrendered person:

(if known)

(first)

(middle)

(maiden if applicable)

(last)

Place

of birth

Date

of birth:

Adoption

finalized in:

(city)

(state)

(state)

(county

Name of

birth mother:

Place

of birth:

(first)

(middle)

(maiden if applicable)

(last)

(city)

(state)

Name of

birth father:

Place

of birth:

(first)

(middle)

(last)

(city)

(state)

Section B.  COMPLETE WHEN OPTIONAL PHOTOGRAPH(S) ARE BEING FILED

Photograph(s) are included with this registration in an unsealed envelope no larger than 8½ x 11 and may be released to the person(s) specified in my Information Exchange Authorization.  These photographs do not include identifying information pertaining to any person other than me.

written signature

Section C.  COMPLETE WHEN OPTIONAL WRITTEN STATEMENT IS BEING FILED

A statement is included on the form provided and may be released to the person(s) specified in my Information Exchange Authorization.  This statement does not include any identifying information pertaining to any person other than me.

written signature

Section D.  CHECKLIST OF ITEMS BEING SUBMITTED

PART I  –  Check if this is an update to a prior registration.

        A completed Medical Questionnaire that is authorized to be released to the registrant(s) specified (check one) is ____

        is not ________ being filed.

PART II – Check if this is a new registration.  (check one)

    $40 personal check or money order payable to the Illinois Department of Public Health or

    A completed Medical Questionnaire that is authorized to be released to registrant(s)

PART III – FOR ALL REGISTRANTS – Check the applicable forms (items) being included.

    Medical Questionnaire

Photocopied proof of identification (always required)

     Notarized Information Exchange Authorization

$40 fee

    Notarized Denial of Information Exchange

Certified copy of the death certificate(s) of the common

    Registration Identification form

birth parent(s) (non-surrendered birth sibling only)

    Adoption Registry Application

Certified copy of the birth certificate of the adopted or

    Optional picture(s)

surrendered person or non-surrendered birth sibling

    Optional written statement

identified in Section A if he/she was NOT BORN IN

THE STATE OF ILLINOIS

THIS CHECKLIST IS IMPORTANT

Certified court order of guardianship if required by registration

Use of the checklist enables you to verify the items included with this registration, before mailing, and alerts our Registry staff to the total contents of the envelope.

VR161 (rev. 05/2000

Illinois Department of Public Health, Division of Vital Records, 605 W. Jefferson St., Springfield, IL  62702-5097.

Printed by Authority of the State of Illinois  P.O.  # 30M 02/00

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 Registry 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

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 Registry 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.