Vital Records Form printable pdf download

Colorado Department of Public Health and Environment

Vital Records Section

Contact Preference Form

Effective 10-01-2003, State Law requires all requests to be accompanied by a photocopy of

your driver’s license, state ID or passport.

Send a $20 non-refundable processing fee payable to Vital Records, photocopy of ID and this form to:

Vital Records, Adoption Specialist, 4300 Cherry Creek Drive South, Denver, CO 80246.

Retain a copy for your records. Your form will be processed within 10 working days or as soon as

possible. Birthparents can change his or her contact preference form by notifying the Adoption Specialist in

writing at any time.

Information To Be Completed By Birth Mother or Birth Father—PLEASE PRINT

Please indicate your status:

￮ birth mother

￮ birth father

Name of child on original birth certificate _________________________________________________________

(First)

(Middle)

(Last)

Child’s complete date of birth ____________________ Child’s place of birth ______________________, Colorado

(Month/day/year)

(City/county)

Gender:  Male  Female

Birth Mother’s complete name as it appears on the original birth certificate, include maiden name and any alias names

used at the time of birth or at the time of relinquishment

___________________________________________________________________________________________

Birth Father’s complete name as it appears on the original birth certificate, include any alias names used at the time of

birth or at the time of relinquishment

___________________________________________________________________________________________

Check all that apply:

I prefer contact by the adult adoptee

, an adult descendant of the adoptee

, or a legal representative of the

adult adoptee or descendant

I would prefer to be contacted through a confidential intermediary

I would prefer to be contacted through a child placement agency

I do not prefer future contact by the adult adoptee

, or adult descendant of the adoptee

, or a legal

representative of the adult adoptee or descendant

If you have authorized contact, please provide a preferred method: mail email _________________________

 phone other ___________________________________________________________________________

If we have any questions about your responses on this form or need additional information, may we contact you by

phone?  Yes  No. If yes, please list a daytime phone number: __________-__________-________________.

Current Legal Name

_____________________________________________________________________________________________________________________

Mailing Address _____________________________________________________________________________

City_________________________________________State_____________________Zip code______________

Signature_______________________________________________________Date_________________

Vital Records Form

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