RETURN TO: NEVADA DEPARTMENT OF HUMAN RESOURCES DIVISION OF CHILD AND FAMILY SERVICES NEVADA DIVISION OF CHILD & FAMILY SERVICES ADOPTION REUNION REGISTRY 4126 TECHNOLOGY WAY, 3RD FLOOR CARSON CITY, NEVADA 89706 ADOPTION REUNION REGISTRY ADOPTEE APPLICATION Please Print Clearly FULL NAME LAST FIRST DATE OF BIRTH / / MIDDLE HOME PHONE NO. ( MAIDEN WORK PHONE NO. ) ( PLACE OF BIRTH CITY SOCIAL SECURITY NUMBER ) - - GENDER STATE MALE FEMALE HOME ADDRESS STREET CITY STATE ZIP MAILING ADDRESS (IF DIFFERENT) STREET CITY STATE ZIP E-MAIL ADDRESS AGENCY THAT HANDLED ADOPTION (IF KNOWN) NAME CITY STATE ADOPTIVE FATHER’S NAME LAST FIRST MIDDLE ADOPTIVE MOTHER’S NAME LAST FIRST MIDDLE I am interested in making contact with my birth or former adoptive parent(s), sibling(s), and/or relatives related within the third degree of consanguinity. I understand contact cannot be made unless these individuals also complete an application for Adoption Reunion Registry. I understand that the information provided on this application will be shared with my birth or former adoptive parents(s), siblings(s), and/or relatives related within the third degree of consanguinity whom also must have a notarized application on file. I understand that I may withdraw this application at any time by notifying the Adoption Reunion Registry in writing. I understand that if I withdraw my application the above individuals will not be able to obtain identifying information about me. I will notify the Adoption Reunion Registry of my whereabouts in the instance I should move. As I provide new information to the Registry, I authorize the Division of Child and Family Services to update this form as requested. ADOPTEE’S SIGNATURE DATE State of____________________________________________________ County of___________________________________________________ Subscribed and sworn to before me this ______________day of______________________________ , ____________ ____________________________________________________________ Notary Public (Notary Stamp) For Office Use Only: (Revised 10/02) (3407) Birth Parent(s) Last Name(s) First Name(s) American LegalNet, Inc. www.FormsWorkflow.com