RESEARCH AND REUNION

Adoptee

Request for Information Form

As an adoptee, whose adoption was facilitated through Catholic Charities, Diocese of Camden, Inc., you may request Social and Medical Information from your adoption record and you may also request Search and Reunion Services. In the event that an adoptee is unable to speak on his/her own behalf due to disability or death, a parent or guardian may request the information on behalf of the adoptee.

In order to verify that we have your adoption file, please complete this form and return it with the other documents in this packet to begin your service request. Completion of this form constitutes a formal request for Search and Reunion from Catholic Charities, Diocese of Camden, Inc., Diocese of Camden, Inc.

Date: ______

I am the Adoptee, Parent of an Adoptee, OTHER, Please specify relationship: ______

If you are not the Adoptee, please state why you are making this request:

PERSONAL INFORMATION

ADOPTEE NAME: (First, Middle, Last) / ______
MAIDEN NAME: (if applicable) / ______
DATE OF BIRTH: / ______
SOCIAL SECURITY NUMBER: / --
CURRENT STREET ADDRESS: / ______
CITY/TOWN: / ______
STATE AND ZIP CODE / ______
IF YOU ARE NOT THE ADOPTEE, PLEASE PROVIDE YOUR NAME AND ADDRESS
NAME: (First, Middle, Last) / ______
STREET ADDRESS: / ______
CITY/TOWN / ______
STATE AND ZIP CODE / ______
PHONE NUMBERS / E-MAIL ADDRESS:
Best Number
to Call / ______
Home ()--
Work ()--
Cell ()--

IS IT PERMISSABLE TO LEAVE A VOICE MESSAGE ON YOUR PHONE? YES NO

NAME AT TIME OF BIRTH: (If Known)
ADOPTIVE FATHER’S NAME:
ADOPTIVE MOTHER’S NAME:
DATE OF FINALIZATION OF ADOPTION (If Known):
BIRTH MOTHER’S NAME: (If Known)
BIRTH FATHER’S NAME: (If Known)

Please complete the information you are willing to share with the person for whom you are searching:

MARITAL STATUS single married separated divorced widowed

SPOUSE’S NAME: ______

TYPE OF WORK YOU DO: ______

NAMES AND AGES OF CHILDREN

NAME / AGE

NAMES OF SIBLINGS

NAME / ALSO ADOPTED?
YES NO
YES NO
YES NO
YES NO

Please list any additional information you would like to share:

______

March, 2017