Relative Application (Part 1)

APPLICANT'S INFORMATION LAST FIRST MIDDLE DATE OF BIRTH PHONE NUMBER OTHER PHONE NUMBER / / ( ) ( ) GENDER MALE FEMALE E-MAIL ADDRESS OR OTHER CONTACT INFORMATION HOME ADDRESS: STREET CITY STATE ZIP CODE MAILING ADDRESS (IF DIFFFERENT) CITY STATE ZIP CODE ADOPTED CHILD INFORMATION BIRTH LAST NAME FIRST MIDDLE NICKNAME OR OTHER NAMES USED DATE OF BIRTH CITY AND STATE WHERE THE CHILD WAS BORN / / NEW ADOPTED NAME (IF KNOWN) LAST FIRST MIDDLE NICKNAME OR OTHER NAMES USED NAME OF ADOPTION AGENCY THAT HANDLED THE ADOPTION NAME(S) OF CHILD'S BIRTH PARENT TO WHOM YOU ARE RELATED LAST FIRST MIDDLE DATE OF BIRTH MALE FEMALE LAST FIRST MIDDLE DATE OF BIRTH MALE FEMALE DESCRIBE SPECIFICALLY HOW YOU ARE RELATED TO THE CHILD (EXAMPLE: BROTHER OF THE BIRTH MOTHER, FATHER OF THE BIRTH FATHER, ETC.) State of County of Subscribed and sworn to before me this day of , 20 by (Notary Stamp)Revised Bjh COMPLETES AN APPLICATION FOR THE ADOPTION REUNION REGISTRY AND THE BIRTH PARENT CONSENTS TO MY OBTAINING THIS INFORMATION. DATE *Contact information can only be released with consent of the birth parent (Part 2). RELATIVE APPLICATION (Part 1)* Please Print Clearly MAIDEN OR OTHER NAMES USED LIMITED TO BLOOD OR STEP-PARENTS, SIBLINGS, GRANDPARENTS, AUNTS, UNCLES, NIECES OR NEPHEWS I AM INTERESTED IN OBTAINING INFORMATION ABOUT THE ABOVE ADOPTEE. I UNDERSTAND I CANNOT RECEIVE ANY INFORMATION UNLESS THE ADOPTEE ALSO STATE CITY I UNDERSTAND THAT NO INFORMATION MAY BE RELEASED UNTIL THE ADOPTEE IS 18 YEARS OLD OR OLDER. Signature of Notary Public IF I WISH TO WITHDRAW THIS APPLICATION AT ANY TIME, I MUST NOTIFY THE ADOPTION REUNION REGISTRY IN WRITING. Print Name of Applicant IT IS MY RESPONSIBILITY TO KEEP THE ADOPTION REUNION REGISTRY CURRENT AS TO ANY CHANGES. ADDRESS, NAME CHANGE, PHONE NUMBER, ETC. I UNDERSTAND THAT THE INFORMATION PROVIDED ON THIS APPLICATION WILL BE SHARED WITH THE ADOPTEE INDICATED ABOVE, IF ALSO REGISTERED. WHEN I PROVIDE NEW INFORMATION TO THE ADOPTION REUNION REGISTRY, THEY ARE AUTHORIZED TO UPDATE MY APPLICATION AS NECESSARY. DIVISION OF CHILD & FAMILY SERVICESADOPTION REUNION REGISTRY Return to: NEVADA DIVISION OF CHILD & FAMILY SERVICES ADOPTION REUNION REGISTRY4126 TECHNOLOGY WAY, 3RD FLOORCARSON CITY, NEVADA 89706 American LegalNet, Inc. www.FormsWorkFlow.com