Adoption Database Registry Registration Form

You may complete this registration form to register your search in the Adoption Database Registry. Registrations submitted without proper contact info or without payment will NOT be posted.    Registration Fee is $10 Due to the volume of Registrants who do not update their contact information when they move or their email address or phone number changes, we are now having to charge a $10 Registration fee to register your search in our Adoption Registry. We take each inquiry very seriously.   Unlike other Registries, we attempt to CALL you if someone inquires on your registration  ........ so it is important that we be able to reach you. We do not rely on email alone since we cannot trust that you read all your email, especially if it should go into your spam folder.  If your contact info is not current, it inflicts additional costs to us to locate you again. Your personal information will be held in confidence and will only be used by the Registry Administrator to reach you in case of a possible match. 1. Registration Number (will be assigned) 2. I am Select One Adoptee Birth Mother Birth Father Birth Sibling (not adopted) Birth Sibling (adopted also) Spouse of Adoptee Other Birth Family Member Friend of Adoptee Friend of Birth Mother Friend of Birth Father Adoptive Mother Adoptive Father Adoptive Sibling Other Adoptive Family Member 3. I am searching for Select One Adoptee Birth Mother Birth Father Birth Sibling (not adopted) Birth Sibling (adopted also) Any Birth Family Member Adoptive Family 4. My First Name & Last Name (current) Name 5. Email Address E-mail 6. Re-enter Email Address E-mail 12. If you have a Facebook account, please provide your Facebook email address which can be found at your Timeline under "About" I understand that if I do not provide a snail mail address or telephone number, my search info will NOT be posted in the Registry. 7. Mailing Address Street address Address (cont.) City State/Province Zip/Postal code Country 8. Home Phone Number Home Phone 9. Alternate Phone Number 10. Best time to Contact if needed 11. Name of Relative or Close Friend to contact if we can not reach you 12. Their Relationship to you 13. Relatives/Friends Complete Address 13 a. Relatives/Friends Phone Number 13 b. Relatives/Friends Email Address Selected info below will be posted in the Adoption Database Registry 14. Adoptees Date of Birth Month of Birth Unknown Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Day of Birth Unknown 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year of Birth Unknown 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 If unsure of date, please insert range or explain here 15. Adoptees Gender Select Gender Female Male Unknown 16. Adoptees Race 17. Adoptees First Name at Birth 18. Adoptees Middle Name at Birth 19. Adoptees Last Name at Birth 20. Adoptees City of Birth 21. Adoptees State of Birth 22. Adoptees County or Providence of Birth 23. Adoptees Country of Birth 24. Birth Mothers First Name 25. Birth Mothers Middle Name 26. Birth Mothers Maiden Name 27. Birth Mothers Last Name at Birth 28a. Birth Mothers Age at time of Birth 28b. Birth Mothers DOB, if known 29. Her regular City & State of Residence at time of Birth 30. Birth Mothers Occupation 31. Birth Fathers First Name 32. Birth Fathers Middle Name 33. Birth Fathers Last Name 34a. Birth Fathers Age at time of Birth 34b. Birth Fathers DOB, if known 35. His regular City & State of Residence at time of Birth 36. Birth Fathers Occupation 37. Birth Mothers & Birth Fathers Marital Status (Married, Unmarried, Divorced - Please explain) 38. Hospital of Birth 39. Doctor 40. Name of Adoption Agency 41. If private adoption, name of attorney or firm 42. County or Providence Adoption took place 43. City Adoption took place 44. State Adoption took place 45. Adoptees Age when Relinquished to Adoptive Parents 46. Adoptees First Name after Adoption 47. Adoptees Middle Name after Adoption 48. Adoptees Last Name after Adoption 49a. Adoptive Mothers First & Last Name 49b. Adoptive Mothers Maiden Name 50. Adoptive Fathers First & Last Name 51. Date Adoption Finalized 52. Did Adoptee have older/younger siblings when relinquished for adoption (Give Details -DOB or ages, sex) 53. Amended Birth Certificate Number 54. Original Birth Certificate Number (if known) 55. The Adoption Database Registry is open for public viewing and is easily pulled up in various search engines. If someone inquires on your registration, do you give the Registry Administrator your permission to provide your email address to the inquirer so they may contact you directly? Select One Yes No 56. Have you applied for your NON ID information from the adoption agency or state vital records? Select One No Yes, have received Yes, has not arrived yet 57. Have you registered with the ISRR (International Soundex Reunion Registry)? If not, download the registration form at http://www.isrr.net/registration.shtml and mail it in. Select One Yes No 58. I hereby agree that I take full responsibility for posting my search information, and furthermore shall not hold the Adoption Database, nor any of its associates liable in any way . Select One Yes I Agree No I Do Not Agree 59. You are invited to join our free Adoption Database Search & Support Group to exchange search ideas with other Triad Members and to receive assistance from many Search Angels within our Group.   Select One Yes, I would like to join No, I am not interested in joining 60. If you replied "yes" to #59, please select one of the mail options as to how you would like to receive email from other Group members.  We currently have over 4,800 members so our Group is very active.  If you don't check your mail box each day, we advise you to select Digest delivery version or you may set up a Google.com account to read the messages at the Group Site.  Select One Individual Email Daily Digest (1 email per day) Read Messages at Group Site 61. How were you referred to Adoption Database?   Select One Internet Search Referred by Dept of Social Services Referred by Adoption Agency Referred by a Friend Referred by a Family Member Newspaper reunion article Television reunion Other 62. OPTIONAL: Adoption Database has teamed with ABC Producers of Extreme Makeover who are piloting the reality show "Find My Family" about search and reunion, featuring families reuniting after years of separation due to an adoption.   There is no cost involved for their assistance, except your agreement to film and air your search and reunion on their upcoming series if all parties are in agreement to do so.  I am interested in the ABC Search & Reunion TV series "Find My Family" and would like the Producers to contact me    Select One Yes I may be interested and would like the Producers to contact me No I am not interested Other 63. Additional Comments (capable of lengthy comments) Please allow a few moments for registration form to transmit. *Note: If you are adoptee searching for another sibling(s) who has been adopted, please complete this registration form with YOUR information. You may complete another registration for the sibling, if you know their information at no additional charge. You can provide any explanations in Comment area.