Free Voluntary Registration Application and Affidavit - Rhode Island

STATE OF RHODE ISLAND & PROVIDENCE PLANTATIONS
FAMILY COURT - PROVIDENCE COUNTY One Dorrance Plaza, Providence, R. I. 02903 (401) 458-3290

VOLUNTARY REGISTRATION APPLICATION AND AFFIDAVIT (Pursuant to Chapter 15-7.2 General Laws of Rhode Island: Passive Voluntary Adoption Mutual Consent Registry Act) FOLDER NUMBER____________________ Registrant's Name (Print) __________________________ DATE ___________________

AFFIDAVIT PERSONS ELIGIBLE TO REGISTER AND USE THE REGISTRY My relationship to the adoptee is that I am the: (check one) ADULT ADOPTEE (Age 21 or older AND Adopted in the State of Rhode Island) BIRTH PARENT Mother Father ADULT GENETIC SIBLING OF ADOPTEE (Age 21 or older) ADOPTIVE PARENT OF A DECEASED ADOPTEE Mother Father PARENT OF A DECEASED BIRTH PARENT(S) Mother Father ADULT SILBLING OF A DECEASED BIRTH PARENT(S) (Age 21 or older) I, the registrant, am seeking identifying information, including genetic, social, and health history (release non-identifying information as soon as possible). I, the registrant, request only non-identifying genetic, social, and health history. REGISTRANT INFORMATION (please print) Are you the adoptee? Yes No

Present Name (First, Middle, Maiden, Last)_____________________________________________ Sex Male Female Date of Birth ________________________

Mailing Address______________________________________________________________ Phone: (Home)_______________________ (Work) ____________________________

Name of Birth Mother (if known)________________________________________________ Name of Birth Father (if known)_________________________________________________ Mailing Address______________________________________________________________ Name at Time of Birth of Adoptee________________________________________________

ADOPTEE INFORMATION (please print) Name at Time of Adoption _______________________________________________________ Sex Male Female Date of Birth _____________________________

Original Name _________________________________________________________________ Place of Birth (City/Town)_________________________(Hospital) _______________________ Adoption Agency (if known) ______________________________________________________ Address_______________________________________________________________________ Adoptive Mother's Name ________________________________________________________ Mailing Address________________________________________________________________ Adoptive Father's Name__________________________________________________________ Mailing Address_________________________________________________________________ Registrant, fill in the following information: 1. Name(s) and address(es) of adult genetic sibling(s) of the adoptee age 21 or older: _______________________________________________________________________________ _______________________________________________________________________________ 2. Name(s) and address(es) of adoptive parents of a deceased adoptee: ________________________________________________________________________________ _________________________________________________________________________________ 3. Name(s) and address(es) of parents of a deceased birth parent: ________________________________________________________________________________ ________________________________________________________________________________ 4. Name(s) and address(es) of adult sibling(s) of a deceased birth parent(s) _________________________________________________________________________________ _________________________________________________________________________________

I, the registrant, understand that: · My application will always remain active unless I send a WRITTEN notice to cancel. · It is my responsibility to update the registry IN WRITING if there is a change of name, address, or telephone number. · The registry is not required to search for a registrant who fails to notify the registry of a change of address. · I, the adoptee, understand that, subsequent to the notification of a match and, prior to the release of identifying information, I must participate in not less than one hour of consultation designed specifically to assist in addressing the manifest issues that may be expected to transpire in such situations. · In the event of a verified match and before any identifying information is released, the registry will send written notice to all eligible registrants and adoptive parents, pursuant to 15-7.2-14, that they can file an objection to the release of any identifying information. If objection is filed, a court hearing is required. · The registry can only release identifying information of the other registrant if there is a match and only non-identifying genetic, social, and medical history if there is no match. Personally appears the undersigned party, who, duly sworn, deposes and says that, as the registrant in this Voluntary Registration Application, I give authority to the registry to release identifying information related to the other relevant persons who register. _______________________________________ _______________________________________ Registrant (Printed Name) Registrant Signature TO BE COMPLETED BY A CLERK/NOTARY PUBLIC State of _________________________________ County of _____________________________________ Before me personally appeared ________________________, known to me to be the person who subscribed to the within instrument, and acknowledged that he/she executed the same. IDENTIFICATION (must check two): State Issued Driver's License U. S. Passport Original Social Security Card State Issued I. D. Card with Photo Other (please specify) _____________________________ IN WITNESS WHEREOF, I have set my hand this _________day of ___________,__________.. _______________________________ Print Name ____________________________________ Clerk or Notary Signature

Each registration shall be accompanied by the original Birth Certificate of the registrant, a death certificate, if required, and a fee of $25.00, made payable to "State of Rhode Island." No registrant shall be accepted, unless the registry is satisfied as to the identity of the registrant. Any registrant who discloses or causes to be disclosed any identifying information about a biological parent or adult adoptee without that person's express written consent shall be guilty of a misdemeanor, punishable by imprisonment for a term of not more than one year, a fine of not more than one thousand dollars ($1,000.00), or both.
(JUV 6/04)