FAMILY COURT ________ CIRCUIT STATE OF HAWAI‘I MEDICAL CERTIFICATE FOR THE CHILD CASE NUMBER FC-A NO. In the Matter of Adoption of 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). The undersigned, being duly licensed to practice medicine in the State of hereby acknowledge that he/she has examined does , and finds that said child’s physical and mental condition is as follows: . Date Signature of Physician Printed Name of Physician Address: Telephone Number: 08/07/01 MEDICAL CERTIFICATE FOR THE CHILD American LegalNet, Inc. www.FormsWorkflow.com