Filing Of Required Non-Identifying Health, Genetic And Social Histories With The Utah Adoption Registry Page 11
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11NON-IDENTIFYING HEALTH, GENETIC & SOCIAL
INFORMATION FOR UTAH ADOPTION REGISTRY
Adoptee’s date of birth: __________________________________________________________
(Month/Day/Year)
Adoptee’s place of birth:__________________________________________________________
(City, County, State, Country)
Birth mother’s residence at time of child’s birth:_______________________________________
(City, County, State, Country)
Date of adoption finalization:______________________________________________________
(Month/Day/Year)
Place of adoption finalization:_____________________________________________________
(City, County, State, Country)
Name/address of agency responsible for placement: ____________________________________
____________________________________
____________________________________
Agency representative to contact for more information:_________________________________
The agency responsible for the placement of this child was unable to obtain any
additional non-identifying health, genetic & social information relating to the child because
(check all that apply):
G
The child’s birth mother failed/refused to provide any information.
G
The child’s birth father failed/refused to provide any information.
G
The identity of the child’s mother is unknown.
G
The identity of the child’s birth father is unknown.
G
Other
(explain):______________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Signature of Agency Representative
06/2013
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