DIVISION OF CHILD AND FAMILY SERVICES ADOPTION REUNION REGISTRY R eturn to: NEVADA DIVISION OF CHILD & FAMILY SERVICES ADOPTION REUNION REGISTRY 4126 TECHNOLOGY WAY, 3RD FLOOR CARSON CITY, NEVADA 89706 CONSENT OF BIRTH PARENT TO RELEASE ADOPTION REUNION REGISTRY INFORMATION (Part 2)* Please Print Clearly I, ___________________________________________________, GIVE MY CONSENT TO FOR THE RELEASE OF INFORMATION REGARDING MY ADOPTED CHILD NAME OF BIRTH PARENT GIVING THIS APPROVAL* _____________________________________________________________________________________ BORN ON ___________________________________________________________ NAME OF CHILD PRIOR TO ADOPTION GENDER DATE OF BIRTH MALE FEMALE TO ________________________________________________________________________, WHO IS MY ___________________________________________________________________ NAME OF RELATIVE RELATIONSHIP IN DETAIL I CERTIFY THAT I AM THE __________________________________________________________________TO THE ABOVE MENTIONED CHILD* BIRTH MOTHER OR BIRTH FATHER OF THE ADOPTED CHILD *I F BI RTH P AREN T I S DECEASED, CON SI DERATI ON M AY BE GI VEN TO DEATH CERTI FI CATE NAME OF BIRTH PARENT LAST FIRST MIDDLE MAIDEN OR OTHER NAMES USED DATE OF BIRTH / / PHONE NUMBER ( ) OTHER PHONE NUMBER ( ) GENDER MALE FEMALE E-MAIL ADDRESS OR OTHER CONTACT INFORMATION HOME ADDRESS: STREET CITY STATE ZIP CODE MAILING ADDRESS (IF DIFFFERENT) CITY STATE ZIP CODE I UNDERSTAND THAT NO INFORMATION MAY BE RELEASED REGARDING THE ADOPTEE UNLESS THE ADOPTEE IS 18 YEARS OLD OR OLDER. I UNDERSTAND THAT NO INFORMATION MAY BE RELEASED TO THE RELATIVE UNLESS BOTH THE RELATIVE AND ADOPTEE HAVE COMPLETED AN APPLICATION FOR THE ADOPTION REUNION REGISTRY AND I HAVE GIVEN MY WRITTEN CONSENT. *IF BIRTH PARENT IS DECEASED, CONSIDERATION MAY BE GIVEN TO DEATH CERTIFICATE. IF I WISH TO WITHDRAW THIS CONSENT, I MAY DO SO AT ANY TIME AND I MUST NOTIFY THE ADOPTION REUNION REGISTRY IN WRITING OF MY INTENTIONS TO WITHDRAW THIS CONSENT. I UNDERSTAND I MAY ALSO COMPLETE A BIRTH PARENT APPLICATION FOR THE ADOPTION REUNION REGISTRY. State of _______________________________ County of ______________________________ Subscribed and sworn to before me this ___________ day of ______________________________, 20________ by_______________________________________________________________ Printed Name of Birth Parent by_______________________________________________________________ Signature of Birth Parent __________________________________________________________________ Signature of Notary Public (Notary Stamp) *If birth parent is deceased, consideration may be made with the submission of the birth parent's death certificate. Revised 9-2016 Bjh American LegalNet, Inc. www.FormsWorkFlow.com American LegalNet, Inc. www.FormsWorkFlow.com