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    Disclosure Request Form for Adoption Information for the Birth Relative

    Personal Details

    Name of Person Requesting Information (required)

    Relationship to Adopted Person (Required)

    Birth MotherBirth FatherBirth SiblingBirth GrandparentOther

    Address 1 (Required)


    City (Required)

    Postal Code (Required)

    Home Phone (Required)

    Work Phone

    Can a Message be Left? (Required)


    Email Address

    Birth Name of Adopted Person(Required)

    Birth Date (yyyy-mm-dd)

    Place of Birth (Required)

    Name of Birth Parent at time of Adoption Placement (Required)

    Placing Agency

    Date of Adoption Placement

    Specific Request or Concerns

    Alternate Contact if Unable to Reach You



    Phone Number