Nevada > Statewide > Division Of Child And Family Services > Adoption
Application For Adoption Registry - Relative 3406 - Nevada
| Application For Adoption Registry - Relative Form. This is a Nevada form and can be used in Adoption Division Of Child And Family Services Statewide . |
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N NEVADA DEPARTMENT OF HUMAN RESOURCES DIVISION OF CHILD AND FAMILY SERVICES RETURN TO: NEVADA DIVISION OF CHILD & FAMILY SERVICES ADOPTION REUNION REGISTRY CARSON CITY, NEVADA ADOPTION REUNION REGISTRY 4126 TECHNOLOGY WAY, 3RD FLOOR 89706 (Limited to persons related to the adopted person within the third degree of consanguinity) RELATIVE APPLICATION Please Print Clearly FULL NAME LAST FIRST MIDDLE MAIDEN DATE OF BIRTH HOME PHONE NO. WORK PHONE NO. SOCIAL SECURITY NUMBER / HOME ADDRESS STREET / ( ) CITY ( ) STATE - ZIP MAILING ADDRESS STREET (IF DIFFERENT) CITY STATE ZIP E-MAIL ADDRESS AGENCY THAT HANDLED ADOPTION NAME (IF KNOWN) CITY STATE NAME(S) OF CHILD'S BIRTH PARENT TO WHOM YOU ARE RELATED OR PRIOR ADOPTIVE PARENT, IF APPLICABLE LAST FIRST MIDDLE DOB LAST FIRST MIDDLE DOB CHILD'S NAME PRIOR TO ADOPTION LAST FIRST MIDDLE DOB GENDER DESCRIBE SPECIFICALLY HOW YOU ARE RELATED TO CHILD, E.G., BROTHER, SISTER OF CHILD'S MOTHER, FATHER OF CHILD'S FATHER, ETC.: I am interested in obtaining information about the above who was adopted. I understand I cannot receive any information unless the child also completes an Application for Adoption Reunion Registry and the birth parent consents to my obtaining this information. I understand that the information provided on this application will be shared with my relatives related within the third degree of consanguinity whom also must have a notarized application on file. I understand that I may withdraw this application at any time by notifying the Adoption Reunion Registry in writing. I understand that if I withdraw my application the child will not be able to obtain identifying information about me. I will notify the Adoption Reunion Registry of my whereabouts in the instance I should move and as I provide new information to the Registry, I authorize the Division of Child and Family Services to update this form as requested. DATE SIGNATURE State of____________________________________________________ County of___________________________________________________ Subscribed and sworn to before me this ______________day of______________________________ , ____________ ____________________________________________________________ Notary Public (Notary Stamp) (MUST COMPLETE PAGE 2 ON REVERSE SIDE) Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com CONSENT OF BIRTH PARENT* TO RELEASE ADOPTION REGISTRY INFORMATION I, (child's name prior to adoption) born on (D.O.B.) to (relative's name) who is my (brother, sister, father, mother, etc.) , give my consent to the release of information regarding , , sex of child , , . I understand no information will be released to the relative or child unless both have completed an Application for Adoption Reunion Registry and I have given my consent. I also understand I, too, may complete an Application for the Registry. I understand I may withdraw my consent at any time by notifying the Adoption Reunion Registry in writing. Date State of____________________________________________________ County of___________________________________________________ Subscribed and sworn to before me this Signature ______________day of______________________________ , ____________ ____________________________________________________________ Notary Public (Notary Stamp) For Office Use Only: Adopting Parent(s) Last Name(s) First Name(s) Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com *Or prior adoptive parent, if applicable (Revised 10/02) (3406)
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