Free Medical Information Fly Sheet - Hawaii

Please affix this form to a manila envelope containing medical information. Do not file these documents. Submit the unsealed envelope when filing your petition for adoption with Legal Documents or to the Family Court Adopiton Clerk if presented after the petition has been filed.

IN THE FAMILY COURT OF THE FIRST CIRCUIT STATE OF HAWAII In the Matter of Adoption of
A [ ]MALE [ ]FEMALE CHILD, Born on: A [ ]MALE [ ]FEMALE CHILD, Born on: A [ ]MALE [ ]FEMALE CHILD, Born on: A [ ]MALE [ ]FEMALE CHILD, Born on: by [ ]the legal spouse of [ ]and

) )
) ) ) ) ) ) ) ) ) ) ) ) ) )

FC-A NO.

[ ]the child(ren)'s legal parent ) [ ]husband and wife [ ]an unmarried person ) ) Petitioner(s). )

) Included in this envelope are the following forms: [ ] Medicial Information Form for: [ ] [ ] [ ] Natural Mother Natural Father

Medical Record Release of the above data for: [ ] [ ] Natural Mother Natural Father

[ ]

Mother's medical records of the child(ren)'s birth and mother's release of these records