Illinois Administrative Code (Last Updated: March 27, 2024) |
TITLE77. PUBLIC HEALTH |
PART500. ILLINOIS VITAL RECORDS CODE |
Section500.APPENDIX E. Adoption Records |
§500.ILLUSTRATION M. Adoptive Parent Registration Identification Form
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Illinois Department of Public Health
ADOPTIVE PARENT REGISTRATION IDENTIFICATION
(Enter all known information.)
I,
, state the following
(first)
(middle)
(last)
I am the
adoptive parent of
Race
(adoptive name)
(first)
(middle)
(last)
Date of birth
Sex
Hospital (if known)
City and state of birth
Name of
adoptive father
(first)
(middle)
(last)
Name of
adoptive mother
(first)
(middle)
(maiden)
(last)
Our/my adopted son/daughter was adopted
through
(approximate date)
(name of agency)
(city and state of agency)
Adopted privately
(state "yes" if applicable)
Adopted person's
birth name (if known)
Race
(first)
(middle)
(last)
Name of
birth mother
Race
(if known)
(first)
(middle)
(maiden)
(last)
Name of
birth father
Race
(if known)
(first)
(middle)
(last)
Other identifying information
Provide name(s) at birth and ages of siblings(s) having a common birth parent with adopted person (if known)
If more than one sibling, please give information requested below on reverse side of this form.
(first)
(middle)
(last)
Date of birth
Sex
Race
(or approximate age)
City and state of birth
Name(s) of common
birth parent(s)
Race
(first)
(middle)
(last)
Race
(first)
(middle)
(last)
(Please note that your registration expires when the adopted person attains the age of 21, unless guardianship extends beyond this time and you have submitted a certified court order of guardianship. A competent adult adopted person must file his or her own registration.)
(signature of adoptive parent)
(date)
(printed or typed name of adoptive parent)
Illinois Department of Public Health, Division of Vital Records, 605 W. Jefferson St., Springfield IL 62702-5097
VR 161.4 (rev. 05/2000)
Printed by Authority of the State of Illinois P.O. # 30M 02/00
(Source: Added at 24 Ill. Reg. 11882, effective July 26, 2000)