N NEVADA DEPARTMENT OF HUMAN RESOURCES DIVISION OF CHILD AND FAMILY SERVICES RETURN TO: ADOPTION REUNION REGISTRY NEVADA DIVISION OF CHILD & FAMILY SERVICES ADOPTION REUNION REGISTRY 4126 TECHNOLOGY WAY, 3RD FLOOR CARSON CITY, NEVADA 89706 RELATIVE APPLICATION (Limited to persons related to the adopted person within the third degree of consanguinity) 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 CITY STATE NAME(S) OF CHILD’S BIRTH PARENT TO WHOM YOU ARE RELATED OR PRIOR ADOPTIVE PARENT, IF APPLICABLE LAST FIRST MIDDLE DOB LAST MIDDLE DOB CHILD’S NAME PRIOR TO ADOPTION LAST FIRST FIRST MIDDLE DOB GENDER DESCRIBE SPECIFICALLY HOW YOU ARE RELATED TO CHILD, E.G., BROTHER, SISTER OF CHILD’S MOTHER, FATHER OF CHILD’S FATHER, ETC.: I am interested in obtaining information about the above who was adopted. I understand I cannot receive any information unless the child also completes an Application for Adoption Reunion Registry and the birth parent consents to my obtaining this information. I understand that the information provided on this application will be shared with my 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 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 and as I provide new information to the Registry, I authorize the Division of Child and Family Services to update this form as requested. DATE SIGNATURE State of____________________________________________________ County of___________________________________________________ Subscribed and sworn to before me this ______________day of______________________________ , ____________ ____________________________________________________________ Notary Public (Notary Stamp) (MUST COMPLETE PAGE 2 ON REVERSE SIDE) Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com CONSENT OF BIRTH PARENT* TO RELEASE ADOPTION REGISTRY INFORMATION , give my consent to the release of information regarding I, , (child’s name prior to adoption) , sex of child born on (D.O.B.) , to (relative’s name) , who is my (brother, sister, father, mother, etc.) . I understand no information will be released to the relative or child unless both have completed an Application for Adoption Reunion Registry and I have given my consent. I also understand I, too, may complete an Application for the Registry. I understand I may withdraw my consent at any time by notifying the Adoption Reunion Registry in writing. Date Signature State of____________________________________________________ County of___________________________________________________ Subscribed and sworn to before me this ______________day of______________________________ , ____________ ____________________________________________________________ Notary Public (Notary Stamp) For Office Use Only: Adopting Parent(s) *Or prior adoptive parent, if applicable (Revised 10/02) (3406) Last Name(s) First Name(s) Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com