FAMILY COURT FIRST CIRCUIT STATE OF HAWAI`I MEDICAL CERTIFICATE FOR THE CHILD CASE NUMBER FC-A No. In the Matter of the Adoption of A [ ] MALE CHILD Born on: A [ ] MALE CHILD Born on: A [ ] MALE CHILD Born on: by [ ] legal spouse of [ ] civil union partner of [ ] and [ ] FEMALE CHILD [ ] FEMALE CHILD [ ] FEMALE CHILD [ ] the child(ren)'s legal parent [ ] a married couple [ ] civil union partners [ ] an unmarried person Petitioner(s). The undersigned, being duly licensed to practice medicine in the State of does hereby acknowledge that he/she has examined and finds that said child's physical and mental condition is as follows: , Date Signature of Physician Print Name of Physician Address: Telephone Number: Ho`okele/FC Adm 2/10/16 Reprographics (2/2016) MEDICAL CERTIFICATE FOR THE CHILD 1F-P-1035 American LegalNet, Inc. www.FormsWorkFlow.com Section 508 Certified