Medical Information Affidavit {1F-P-2029}

Please affix this form to a manila envelope containing medical information. Do not file these documents. Submit the unsealed envelope when filing your petition for adoption with Legal Documents or to the Family Court Adopon Clerk if presented after the petition has been filed. IN THE FAMILY COURT OF THE FIRST CIRCUIT STATE OF HAWAII In the Matter of Adoption of ) FC-A NO. A [ ]MALE [ ]FEMALE CHILD, Born on:A [ ]MALE [ ]FEMALE CHILD, Born on:A [ ]MALE [ ]FEMALE CHILD, Born on:A [ ]MALE [ ]FEMALE CHILD, Born on:by ) ) ) ) ) ) ) ) ) ) ) ) [ ]the legal spouse of [ ]and ) ) [ ]the child(ren)'s legal parent ) ) [ ]husband and wife [ ]an unmarried person ) ) Petitioner(s). ) ) Included in this envelope are the following forms: [ ] Medical Information Form for: [ ] Natural Mother [ ] Natural Father [ ] Medical Record Release of the above data for: [ ] Natural Mother [ ] 003Natural Father [ ] 003Mother222s medical records of the child(ren)222s birth and mother222s release of these records 003003 American LegalNet, Inc. www.FormsWorkFlow.com