PARENT'S CONSENT/DENIAL TO RELEASE INFORMATION TO ADULT ADOPTEE Michigan Department of Health and Human Services Central Adoption Registry A new statement may be sent to the Central Adoption Registry any time to withdraw a previous consent or to withdraw a previous denial. Release of identifying information will be based on the most recent statement on file in the Central Adoption Registry. A parent giving consent should send to the Central Adoption Registry a new statement if either his/her name or address changes. A separate form must be filled out for each child for whom you are giving consent/denial. Send this original form and a copy of an approved photo identification to the Central Adoption Registry address below: MICHIGAN DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTRAL ADOPTION REGISTRY PO BOX 30037 LANSING MI 48909 I state that I am the father mother of the child described below. I hereby give consent do not give consent* to the release of my name and address to this child when he/she is 18 years of age or older. (*If the denial box is checked, the parent may provide an explanation as to why he/she does not wish to release name and address). Reason: A copy of an approved photo identification is included with this form. (Example: Current driver's license, current state issued photo identification or current student photo ID) CHILD INFORMATION: FOR OFFICE USE ONLY Birth Date Child's Full Name at Birth Child's Birth Date (Mo., Day, Yr.) Child's City of Birth Child's County of Birth Child's State of Birth Child's Birth Mother's Name When Parental Rights were Released or Terminated PARENT INFORMATION: My Current Name My Birth Date (Mo., Day, Yr.) My Current Address (Street Number and Name) Apartment or Lot Number City State Zip Code Telephone Number Adoptee's Birth Name (Last, First, Middle) Email Signature Date The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability. AUTHORITY: MCLA 710.68. COMPLETION: Voluntary. PENALTY: None DISTRIBUTION: ORIGINAL - Michigan Department of Health and Human Services Central Adoption Registry PO Box 30037 Lansing, Michigan 48909 COPY Keep for your records. DHS-1919 (Rev. 3-16) Previous edition obsolete. American LegalNet, Inc. www.FormsWorkFlow.com