Application For Inclusion In The Utah Mutual-Consent Voluntary Adoption Registry Form - Utah Department Of Health
ADVERTISEMENT
1
2UTAH DEPARTMENT OF HEALTH - OFFICE OF VITAL RECORDS & STATISTICS
APPLICATION FOR INCLUSION IN THE UTAH
MUTUAL-CONSENT VOLUNTARY ADOPTION REGISTRY
All applicants must complete Sections 1 and 3. Adult adoptees should complete as much as possible in
section 3. However, only the birth date and birth place are critical for making the match. The birth parent(s)
should complete as much as possible in Sections 3 and 4. It is important that the birth date and birth place
be provided to enable a match to be made. The birth mother should also complete lines A and B in section
4. The birth father should complete lines B and C in Section 4.
Section 1 A. Name of Person Registering_______________________________________________
B. Current Address________________________________________________________
C. Current Telephone Number (include Area Code)_______________________________
Section 2
Person Registering is (Please check one)
A. _____ Adult Adoptee
D. _____ Adult Blood Related Brother or
Sister of Adoptee
B. _____ Birth Parent
E. _____ Adult Brother or Sister of
C. _____ Adoptive parent of Deceased
Deceased Birth Parent
Adoptee
F. _____ Parent of Deceased Birth Parent
Section 3
Information About the Adoptee:
A. Birth Name_____________________________________________________ Sex:________
B. Adoptive Name______________________________________________________________
C. Current Name_______________________________________________________________
D. Birth Date and Birth Place_____________________________ Hospital _________________
E. Names of Adoptive Parents____________________________________________________
F. Adoption/Placing Agency, if known______________________________________________
Section 4
Information About Adoptees Birth Parent(s):
A. Mother’s Current Name_______________________________________________________
B. Mother’s Name at Time of Adoption_____________________________________________
C. Father’s Current Name_______________________________________________________
I hereby authorize the Office of Vital Records and Statistics to identify me to any and all who register with
the Utah Mutual Consent Voluntary Adoption Registry and who are authorized to know my identity. I have
attached a certified copy of my birth certificate, that will be returned to me following registration of this
document. I make this affidavit for the purpose of registering, pursuant to Section 78b-6-144 of the Utah
Code. I understand that I may withdraw this application at any time by submitting a written, notarized request
to Vital Records. I understand that If I withdraw my application, no one will be able to obtain identifying
information about me.
Subscribed and Sworn to before me this _______________Day of _____________________, 20______.
________________________________________
________________________________________
Signature of Person Registering
Notary Public
S
E
A
L
FEE REC’D:
$25.00
For OFFICE USE ONLY (do not write below)
PAID: Check
Cash
Money Order
Credit Card
Request # _________
Clerks Initials___________
Revised 05/09
ADVERTISEMENT
0 votes
Related Articles
Related forms
Application For Permit To Mix, Blend And/or Distributealcohol-gasoline Blends Form - Mississippi Department Of Agriculture And Commerce
Legal
Utah Department Of Health, Child Care Licensing Initial Cbs / Lis Consent And Release Of Liability For Child Care
Legal
Voluntary Caregiver Registration Form - Colorado Department Of Public Health And Environment
Business
Related Categories
Parent category: Legal