"Birth Parent Application Form" - Nevada

Birth Parent Application Form is a legal document that was released by the Nevada Department of Health and Human Services - a government authority operating within Nevada.

Form Details:

  • Released on December 1, 2016;
  • The latest edition currently provided by the Nevada Department of Health and Human Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Nevada Department of Health and Human Services.

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Download "Birth Parent Application Form" - Nevada

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R eturn to:
NEVADA DIVISION OF CHILD & FAMILY SERVICES
DIVISION OF CHILD AND FAMILY SERVICES
ADOPTION REUNION REGISTRY
4126 TECHNOLOGY WAY, 3RD FLOOR
ADOPTION REUNION REGISTRY
CARSON CITY, NEVADA 89706
BIRTH PARENT APPLICATION
Please Print Clearly
NAME OF BIRTH PARENT
LAST
FIRST
MIDDLE
MAIDEN OR OTHER NAMES USED
OTHER PHONE NUMBER
DATE OF BIRTH
PHONE NUMBER
GENDER
MALE
FEMALE
(((
)
/
/
(
)
E-MAIL ADDRESS OR OTHER CONTACT INFORMATION
INMATE #:
(if applicable)
HOME ADDRESS: STREET
CITY
STATE
ZIP CODE
MAILING ADDRESS: (IF DIFFFERENT)
CITY
STATE
ZIP CODE
OTHER BIRTH PARENT'S NAME AND INFORMATION (IF KNOWN)
LAST
FIRST
MIDDLE
MAIDEN OR OTHER NAMES USED
DATE OF BIRTH
PHONE NUMBER
OTHER PHONE NUMBER
MALE
GENDER
FEMALE
/
/
(
)
(((
)
E-MAIL ADDRESS OR OTHER CONTACT INFORMATION
INMATE #:
(if applicable)
MAILING ADDRESS: STREET
CITY
STATE
ZIP CODE
CHILD'S BIRTH NAME
LAST
FIRST
MIDDLE
NICKNAME OR OTHER NAMES USED
CHILD'S DATE OF BIRTH
CITY AND STATE WHERE THE CHILD WAS BORN
GENDER
MALE
FEMALE
/
/
I AM INTERESTED IN MAKING CONTACT WITH MY CHILD WHO WAS ADOPTED. I UNDERSTAND THAT CONTACT CANNOT BE MADE UNLESS MY CHILD ALSO COMPLETES AN
APPLICATION FOR THE ADOPTION REUNION REGISTRY & I UNDERSTAND THAT MY CHILD CANNOT COMPLETE THE APPLICATION UNTIL HE/SHE IS 18 YEARS OF AGE.
I UNDERSTAND THAT THIS APPLICATION IS ONLY FOR MYSELF AND REGARDING THE CHILD INDICATED ON THIS APPLICATION.
IF I WISH TO WITHDRAW THIS APPLICATION AT ANY TIME, I MUST NOTIFY THE ADOPTION REUNION REGISTRY IN WRITING BY SUBMITTING A CHANGE FORM.
IT IS MY RESPONSIBILITY TO KEEP THE ADOPTION REUNION REGISTRY CURRENT AS TO ANY CHANGES: ADDRESS, NAME CHANGE, PHONE NUMBER, ETC.
WHEN I PROVIDE NEW INFORMATION TO THE ADOPTION REUNION REGISTRY, THEY ARE AUTHORIZED TO UPDATE MY APPLICATION AS NECESSARY.
_______________________________________________________________
___________________________
SIGNATURE OF BIRTH PARENT
DATE
State of _______________________________
County of ______________________________
Subscribed and sworn to before me this ___________ day of ______________________________, 20________
by_______________________________________________________________
Print Name of Applicant
_________________________________________________________________
Signature of Notary Public
(Notary Stamp)
ADOPTION AGENCY INFORMATION
NAME OF ADOPTION AGENCY THAT HANDLED THE ADOPTION
CITY
STATE
CHILD'S ADOPTED NAME
LAST
FIRST
MIDDLE
NICKNAME OR OTHER NAMES USED
NAME OF ADOPTIVE PARENT #1
LAST
FIRST
MIDDLE
GENDER
MALE
FEMALE
NAME OF ADOPTIVE PARENT #2
LAST
FIRST
MIDDLE
GENDER
MALE
FEMALE
Revised 12-2016 Bjh
R eturn to:
NEVADA DIVISION OF CHILD & FAMILY SERVICES
DIVISION OF CHILD AND FAMILY SERVICES
ADOPTION REUNION REGISTRY
4126 TECHNOLOGY WAY, 3RD FLOOR
ADOPTION REUNION REGISTRY
CARSON CITY, NEVADA 89706
BIRTH PARENT APPLICATION
Please Print Clearly
NAME OF BIRTH PARENT
LAST
FIRST
MIDDLE
MAIDEN OR OTHER NAMES USED
OTHER PHONE NUMBER
DATE OF BIRTH
PHONE NUMBER
GENDER
MALE
FEMALE
(((
)
/
/
(
)
E-MAIL ADDRESS OR OTHER CONTACT INFORMATION
INMATE #:
(if applicable)
HOME ADDRESS: STREET
CITY
STATE
ZIP CODE
MAILING ADDRESS: (IF DIFFFERENT)
CITY
STATE
ZIP CODE
OTHER BIRTH PARENT'S NAME AND INFORMATION (IF KNOWN)
LAST
FIRST
MIDDLE
MAIDEN OR OTHER NAMES USED
DATE OF BIRTH
PHONE NUMBER
OTHER PHONE NUMBER
MALE
GENDER
FEMALE
/
/
(
)
(((
)
E-MAIL ADDRESS OR OTHER CONTACT INFORMATION
INMATE #:
(if applicable)
MAILING ADDRESS: STREET
CITY
STATE
ZIP CODE
CHILD'S BIRTH NAME
LAST
FIRST
MIDDLE
NICKNAME OR OTHER NAMES USED
CHILD'S DATE OF BIRTH
CITY AND STATE WHERE THE CHILD WAS BORN
GENDER
MALE
FEMALE
/
/
I AM INTERESTED IN MAKING CONTACT WITH MY CHILD WHO WAS ADOPTED. I UNDERSTAND THAT CONTACT CANNOT BE MADE UNLESS MY CHILD ALSO COMPLETES AN
APPLICATION FOR THE ADOPTION REUNION REGISTRY & I UNDERSTAND THAT MY CHILD CANNOT COMPLETE THE APPLICATION UNTIL HE/SHE IS 18 YEARS OF AGE.
I UNDERSTAND THAT THIS APPLICATION IS ONLY FOR MYSELF AND REGARDING THE CHILD INDICATED ON THIS APPLICATION.
IF I WISH TO WITHDRAW THIS APPLICATION AT ANY TIME, I MUST NOTIFY THE ADOPTION REUNION REGISTRY IN WRITING BY SUBMITTING A CHANGE FORM.
IT IS MY RESPONSIBILITY TO KEEP THE ADOPTION REUNION REGISTRY CURRENT AS TO ANY CHANGES: ADDRESS, NAME CHANGE, PHONE NUMBER, ETC.
WHEN I PROVIDE NEW INFORMATION TO THE ADOPTION REUNION REGISTRY, THEY ARE AUTHORIZED TO UPDATE MY APPLICATION AS NECESSARY.
_______________________________________________________________
___________________________
SIGNATURE OF BIRTH PARENT
DATE
State of _______________________________
County of ______________________________
Subscribed and sworn to before me this ___________ day of ______________________________, 20________
by_______________________________________________________________
Print Name of Applicant
_________________________________________________________________
Signature of Notary Public
(Notary Stamp)
ADOPTION AGENCY INFORMATION
NAME OF ADOPTION AGENCY THAT HANDLED THE ADOPTION
CITY
STATE
CHILD'S ADOPTED NAME
LAST
FIRST
MIDDLE
NICKNAME OR OTHER NAMES USED
NAME OF ADOPTIVE PARENT #1
LAST
FIRST
MIDDLE
GENDER
MALE
FEMALE
NAME OF ADOPTIVE PARENT #2
LAST
FIRST
MIDDLE
GENDER
MALE
FEMALE
Revised 12-2016 Bjh