NEVADA DEPARTMENT OF HUMAN RESOURCES DIVISION OF CHILD AND FAMILY SERVICES RETURN TO: NEVADA DIVISION OF CHILD & FAMILY SERVICES ADOPTION REUNION REGISTRY 4126 TECHNOLOGY WAY, 3RD FLOOR CARSON CITY, NEVADA 89706 ADOPTION REUNION REGISTRY BIRTH PARENT APPLICATION Please Print Clearly FULL NAME LAST FIRST HOME PHONE NO. DATE OF BIRTH / MIDDLE / WORK PHONE NO. ( ( MAIDEN ) SOCIAL SECURITY NUMBER ) - - HOME ADDRESS STREET CITY STATE ZIP MAILING ADDRESS (IF DIFFERENT) STREET CITY STATE ZIP E-MAIL ADDRESS AGENCY THAT HANDLED ADOPTION (IF KNOWN) NAME CHILD WHO WAS ADOPTED LAST CITY FIRST STATE MIDDLE GENDER MALE CHILD’S DATE OF BIRTH / CHILD’S PLACE OF BIRTH CITY FEMALE STATE / BIRTH MOTHER’S NAME AT TIME OF ADOPTION LAST FIRST MAIDEN AKA I am interested in making contact with my child who was adopted. I understand that contact cannot be made unless my child also completes an application for Adoption Reunion Registry. I understand that my child cannot complete the application until he or she is eighteen years old. I understand that the information provided on this application will be shared with my birth sibling(s) 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, my child 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. BIRTH PARENT’S SIGNATURE DATE State of____________________________________________________ County of___________________________________________________ Subscribed and sworn to before me this ______________day of______________________________ , ____________ ____________________________________________________________ Notary Public (Notary Stamp) For Office Use Only: Adopting Parent(s) Last Name(s) First Name(s) (Revised 10/02) (3408) American LegalNet, Inc. www.FormsWorkflow.com