STATE OF RHODE ISLAND & PROVIDENCE PLANTATIONS FAMILY COURT - -PROVIDENCE COUNTY One Dorrance Plaza, Providence, RI 02903 (401) 458-3290 VOLUNTARY REGISTRATION APPLICATION AND AFFIDAVIT PURSUANT TO CHAPTER 15-7.2 GENERAL LAWS OF RHODE ISLAND PASSIVE VOLUNTARY ADOPTION MUTUAL CONSENT REGISTRY ACT FOLDER NUMBER___________________ ____________________________________ REGISTRANTS NAME (PRINT) DATE_______________________________ AFFIDAVIT PERSONS ELIGIBLE TO REGISTER AND USE THE REGISTRY MY RELATIONSHIP TO THE ADOPTEE IS THAT I AM THE: (check one) ADULT ADOPTEE (age 21 or older) (Adopted in the State of RI) BIRTH PARENT ADOPTIVE PARENT OF A DECEASED ADOPTEE PARENT OF A DECEASED BIRTH PARENT MOTHER MOTHER MOTHER FATHER FATHER FATHER ADULT GENETIC SIBLING OF ADOPTEE (age 21 or older) ADULT SIBLING OF A DECEASED BIRTH PARENT(S) (age 21 or older) I, the registrant, am seeking identifying information including genetic, social and health history. (Release non-identifying information as soon as possible.) I, the registrant, request only non-identifying genetic, social and health history. REGISTRANT INFORMATION: (please print) ARE YOU THE ADOPTEE? Yes No __________________________________________________________ Present Name (First, Middle, Maiden, Last) Sex__________________________ Date of Birth_________________________ ______________________________________________________________________________ Mailing Address Phone: (home)_________________________ (work)______________________________ Name of Birth Parent (Mother or Father) __________________________________________ Mailing Address_________________________________________________________________ Name At Time Of Birth Of Adoptee _________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com ADOPTEE INFORMATION (print) Birth Name At Time Of Adoption ___________________________________________________ Sex________________ Date Of Birth_____________________________________________ Original Name____________________________________________________________________ Place of Birth (City/Town)__________________________Hospital__________________________ Adoption Agency (if known)_________________________________________________________ Adoptive's Mother's Name _________________________________________________________ Mailing Address_____________________________________________________________ Adoptive's Father's Name _________________________________________________________ Mailing Address______________________________________________________________ Registrant, fill in the following information: 1. Name(s) and addresses of all the adult genetic sibling(s) of the adoptee age 21 or older: _________________________________________________________________________ _________________________________________________________________________ 2. Name and address of adoptive parents of a deceased adoptee: _________________________________________________________________________ __________________________________________________________________________ 3. Name and address of parents of a deceased birth parent: __________________________________________________________________________ __________________________________________________________________________ 4. Names and addresses of adult siblings of a deceased birth parent or parents: __________________________________________________________________________ __________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com I, the registrant, understand that: My application will always remain active unless I send a WRITTEN notice to cancel. It is my responsibility to update the registry IN WRITING if there is a change of name, address or telephone number. The registry is not required to search for a registrant who fails to notify the registry of a change of address. I the adoptee understand that subsequent to the notification of a match, and prior to the release of identifying information, I must participate in not less than one hour of consultation designed specifically to assist in addressing the manifest issues that may be expected to transpire in such situations. In the event of a verified match and before any identifying information is released, the registry will send written notice to all eligible registrants and adoptive parents pursuant to 157.2-14, that they can file an objection to the release of any identifying information. If objection is filed a court hearing is required. The registry can only release identifying information of the other registrant if there is a match and only non-identifying genetic, social and medical history if there is no match. Personally appears the undersigned party, who being duly sworn, deposes and says that as the registrant in this Voluntary Registration Application, I give authority to the registry to release identifying information related to the other relevant persons who register. __________________________________ Registrant ­ Print Name ________________________________________ Signature of Registrant TO BE COMPLETED BY A CLERK/NOTARY PUBLIC State of __________________________________ County of _____________________________________ Before me, personally appeared _____________________________________________ known to me to be the person who subscribed to the within instrument, and acknowledged that he/she executed the same. IDENTIFICATION (must check two) State Issued Drivers License Original Social Security Card U.S. Passport State Issued I.D. Card with Photo Other (specify) _________________________________________________________ IN WITNESS WHEREOF, I have set my hand this ________ day of ____________, ____________. ____________________________________ Print Name _______________________________________ Clerk or Notary Signature American LegalNet, Inc. www.FormsWorkFlow.com Each registration shall be accompanied by the Birth Certificate (long form) of the registrant, a death certificate if required, and a fee of $25.00 payable to "State of Rhode Island". No registration shall be accepted unless the registry is satisfied as to the identity of the registrant. Any registrant who discloses or causes to be disclosed identifying information about a biological parent or adult adoptee without that person's express written consent shall be guilty of a misdemeanor punishable by imprisonment for a term of not more than one year, or a fine not more than one thousand dollars ($1,000), o