IN THE CIRCUIT COURT FOR THE TWENTY-THIRD JUDICIAL CIRCUIT DEKALB COUNTY, ILLINOIS _________________________________ _________________________________ Petitioner(s), vs. __________________________________ __________________________________ Respondent(s). ) ) ) ) ) ) ) CASE NO. _______________________________ ACKNOWLEDGEMENT OF INFORMATION ON THE ILLINOIS ADOPTION REGISTRY AND MEDICAL INFORMATION EXCHANGE I, _________________________________ have signed the Final and Irrevocable Consent to Adoption (relationship, e.g., mother, father, guardian) for a child born on _____________________________ at ____________________________________. I have been given the Illinois Department of Public Health "Illinois has put the option back in adoption" which provides information on the Illinois Adoption Registry and Medical Information Exchange. _______________________________________________________ Name ___________________________________________, 20_________ Date Acknowledgement of IL Adoption Registry & Medical Info 04-01-16 lks American LegalNet, Inc. www.FormsWorkFlow.com