PETITION

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Have you sent your information to the Indiana Adoption History Program? yes no

Have you received your non-identifying information? yes no

Have you registered with the Indiana Adoption Coalition? yes no

May information on this questionnaire be added to the IAC Registry? yes no

Do you have a verifiable need to receive or pass on medical information? yes no

If so, will your doctor sign a statement to that effect? yes no



1a What is your full name and age. Include all names under which file may be located

1b What is your current address and phone number?

1c What is your relationship to the adopted person? Adoptee Birthparent Sibling


SECTION2

2a Adopted person's full name(include both birth and adopted name is known)

2b What is the gender of the adopted person?

2c Date and place of birth of adopted person

2d Current address of the adopted person

2e County of adoption proceeding

2f Case number of adoption

2g Name and address of agency or individual placing the adopted person

2h Full name and current address of adopting parent

2i Date of adoption proceedings

2j Full name(s) and current address of birth parents

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Why do you believe that getting this information will be helpful to you or to others?

Any additional questions?

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