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1. Registration Number (will be
assigned)
2. First Name & Last Name (current)
Name
3. Email Address
4. Re-enter Email Address
5. Mailing Address
Street address
Address
(cont.)
City
State/Province
Zip/Postal
code
Country
6. Home Phone Number
Home Phone
7. Alternate Phone Number
8. Best time to Contact if needed
9. Name of Relative or Close
Friend
10. Their Relationship to you
11. Relatives/Friends Complete
Address
11 a. Relatives/Friends Phone
Number
Selected info below will be posted in
Emergency Medical Locators Registry
12. Adoptees Date of Birth If
unsure of date, please insert range or explain here
13. Adoptees Gender
14. Adoptees Race
15. Adoptees First Name at Birth
16. Adoptees Middle Name at Birth
17. Adoptees Last Name at Birth
18. Adoptees City of Birth
19. Adoptees State of Birth
20. Adoptees County or Providence of
Birth
21. Adoptees Country of Birth
22. Birth Mothers First Name
23. Birth Mothers Middle Name
24. Birth Mothers Maiden Name
25. Birth Mothers Last Name at Birth
26. Birth Mothers Age at time of
Birth
27. Birth Mothers City & State of
Residence
28. Birth Mothers Occupation
29. Birth Fathers First Name
30. Birth Fathers Middle Name
31. Birth Fathers Last Name
32. Birth Fathers Age at time of
Birth
33. Birth Fathers City & State of
Residence
34. Birth Fathers Occupation
35. Birth Mothers & Birth Fathers
Marital Status
(Married, Unmarried, Divorced - Please
explain)
36. Hospital of Birth
37. Doctor
38. Name of Adoption Agency
39. If private adoption, name of
attorney or firm
40. County Adoption took place
41. City Adoption took place
42. State Adoption took place
43. Adoptees Age when Relinquished to
Adoptive Parents
44. Adoptees First Name after
Adoption
45. Middle Name after Adoption
46. Last Name after Adoption
47. Adoptive Mothers First & Last
Name
48. Adoptive Fathers First & Last
Name
49. Date Adoption Finalized
50. Did Adoptee have older/younger
siblings when relinquished for adoption
(Give Details -DOB or ages, sex)
51. Amended Birth Certificate Number
52. Original Birth Certificate Number
(if known)
53. Will photo be downloaded to afseml@yahoo.com
to post in PHOTO DATABASE?
54. As we post to the Adoption Free
Search Registry a for the public to view, do you choose to
display your email address or not? (If someone recognizes
any info, they might be more encouraged to send an email to
you directly rather than go through someone to forward on)
55. Have you applied for your NON
ID information from the adoption agency?
56. Your Triad position *Note: If
you are birth sibling searching for another sibling who has
been adopted, please complete this registration form with
THEIR information, and yourself as the searcher.
**If you are searching for more
than one sibling, please complete a form for each.
57. Have you registered with the
ISRR (International Soundex Reunion Registry)? If not,
download the registration form at http://www.plumsite.com/isrr/
and snail mail it.
58. Since no one can guarantee a
sucessful reunion each and every time, I hereby agree that I
shall not hold Emergency Medical Locators Emergency Medical
Locators nor any of its members or search angels liable in
their attempt to help me or in the outcome of my search
59. Verification ~ I hereby choose and
give my permission to post my adoption search in Adoption
Free Search Registry,
(I understand that if I do not
provide a snail address or phone number, my search info will
not be posted)
60. Is this an urgent or
emergency medical search?
61. List Urgent Medical Conditions
which would constitute an Emergency Search
62.
Additional Comments Please copy and paste the entire
registration form into an email and send to:
afseml@aol.com |
