NEW YORK STATE DEPARTMENT OF HEALTH
Vital Records Adoption Information Registry
Adoptee Registration Form
COMPLETE THIS APPLICATION
AND RETURN TO: REGISTRY NUMBER
DATE
New York State Department of Health
Adoption Information Registry
P.O. Box 2602 OFFICIAL USE ONLY
Albany, NY 12220-2602
NOTE: This registration can be accepted only if the adoptee was born or adopted in New York State. Complete as much
information as possible and include a copy of adoptee's birth certificate and adoption order, if available.
Please indicate if this registration is for: (check all that apply)
Non-identifying information (*) - Available general and medical information about biological parents at time of
adoption.
Non-identifying Medical Information (**) - Updated medical information, if/when submitted by biological parents
after the adoption.
Identifying information - Parents (***) - About biological parents, if/when registered.
Identifying Information - Siblings (***) - About biological siblings, if/when registered.
(*) Adoptee must be 18 years of age or older.
(**) No age restriction, but adoptive parent must sign this registration, if adoptee is under 18 years of age.
(***) Adoptee must be 18 years of age or older. Unless this box is checked, you will not be notified of a match even if your birth
parents or biological siblings are registered.
Note: If the Adoption Registry determines that an agency was involved in your adoption, non-identifying and
identifying information will be released to you by the agency .
PLEASE COMPLETE ALL INFORMATION. MISSING INFORMATION MAY DELAY PROCESSING.
1. Name and address of adoptee
CURRENT LAST FIRST MIDDLE ADOPTED LAST NAME
MAILING ADDRESS STREET CITY/TOWN
( )
STATE ZIP CODE TELEPHONE NUMBER
2. Date of birth of adoptee
MM / DD / YYYY
3. Adoptive parents
A. MOTHER/PARENT: CURRENT LAST FIRST MIDDLE BIRTH LAST (if different)
B. FATHER/PARENT: CURRENT LAST FIRST MIDDLE BIRTH LAST (if different)
C. ADDRESS AT TIME OF ADOPTION, if known STREET CITY/TOWN
STATE ZIP CODE
4. Place of birth of adoptee
HOSPITAL, if known
CITY, TOWN OR VILLAGE COUNTY/BOROUGH
DOH-30 (4/14) Page 1 of 2
5. Indicate the name of the agency and court of adoption, if known
A. NAME OF AGENCY
CITY, TOWN OR VILLAGE COUNTY/BOROUGH
Check box if you have already received non-identifying information from adoption agency.
Date received:
MM / DD / YYYY
B. NAME OF COURT C. DATE OF ADOPTION: MM / DD / YYYY
6. Is the adoptee in contact with birth brother(s) and/or sister(s)?
YES NO If yes, please provide the following information for each sibling with whom adoptee is in contact.
NAME DATE OF BIRTH ADDRESS (include zip code)
1.
2.
3.
4.
5.
6.
7.
7. Signature and Notarization.
h
e
State of
County of g SS.
I solemnly attest that all of the information provided on this application
is true and accurate to the best of my knowledge under the penalty of
perjury.
Sworn to before me this Day
SIGNATURE OF REGISTRANT
Signature must be notarized Of , .
NOTE: Adoptive Parent must sign if the adoptee is under 18
years of age. Notarization must include Notary's
stamp or raised seal. Notary Public
DOH-30 (4/14) Page 2 of 2
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