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Form Adph-Hs-86 - Request To Place A Contact Preference And Medical History Form With The Child'S Original Birth Certificate Page 3

CONTACT PREFERENCE AND MEDICAL HISTORY FORM

FOR

BIRTH PARENT(S) OF ADOPTED CHILDREN BORN IN ALABAMA

This form will be placed with the original birth certificate in the “sealed file” for your child. If the child

requests a copy of his/her original birth certificate after this Contact Preference and Medical History

Form has been placed in the sealed file, this form will be given to the child along with copies of all other

documents in the file. This Contact Preference Form is considered a private communication from the

birth parent to the child and no copies of this form will be given to anyone other than the child.

I am the: ________ Birth Mother

_________ Birth Father

Date of completion of this form: __________________________________________________

=============================================================================

INFORMATION NECESSARY TO LOCATE THE ORIGINAL BIRTH CERTIFICATE

The information requested below must be stated exactly as it is on the original birth certificate or we will

not be able to confirm that we have located the right record. Please print legibly.

Date of Child’s Birth ______________________________

Sex: ____ Male ____ Female

County or City of Birth _________________________________________________________

Mother’s Name as Shown on Birth Certificate ______________________________________

=============================================================================

STATE YOUR PREFERENCE ABOUT CONTACT WITH THE ADOPTED CHILD

______

I Would Like to Be Contacted.

Current Name: ______________________________________________________

Address: ___________________________________________________________

__________________________________________________________________

Telephone: _________________________________________________________

Other Contact Information: ____________________________________________

__________________________________________________________________

______

I Would Prefer to Be Contacted Only Through an Intermediary.

______

I Prefer Not to Be Contacted at This Time. If I decide later that I would like to be

contacted, I will submit an updated Contact Preference Form to the State Registrar of

Vital Statistics. I have completed the Medical History Section of this form to be

provided to the child.

Page 1 of 4 ADPH-HS-87/10/2009

Form Adph-Hs-86 - Request To Place A Contact Preference And Medical History Form With The Child'S Original Birth Certificate Page 3