PAC on Line Registration form

PA ADOPTION CONNECTION

898 High Point Road, Fort Hill, PA 15540

(814) 395-3938

E-mail: Gshay@aol.com

MEMBERSHIP REGISTRATION (All information is confidential.) PLEASE complete this form and return it to the above address in order to have your name and search information entered in the PAC computerized registry and mailing list.

Member Information:

Full Name:__________________________________________________________ Birth Date: _____________________________________________

Address: ___________________________________________________________ Social Security No.: ______________________________________

City: ______________________________________________________________ State:_______________ Zip Code:__________________________

Home phone:(______)________________________ Work Phone: (______)________________________ E-mail: ______________________________

I am: (please circle your choice) Adoptee Birthparent Adoptive Parent Sibling Other____________________________________________

Information about the child: Child is: Male _____ Female _____Birth Date: (Month/Day/Year: _________________________________ Time:_____________ AM PM Birth Weight: _________ lb _________ozHospital (Birth Place): __________________________________________________ Attending Physician: ________________________________City of Birth: ________________________________________________ County_____________________________________ State:___________Name Given at Birth: _____________________________________________________________________________________________________Name Given at Adoption: __________________________________________________________________________________________________Birth Certificate #s — File #:__________________________________________________________________________Was this a plural birth?: _____________ How many females?: ________ How many males?: ________Court of Jurisdiction ______________________________________ City: ____________________ County:_______________________ State: ____Attorney of Record: ___________________________________________________________ Date of Final Decree: _________________________Adoption Decree #: ____________________________________ Was this adoption: Private______ By an Agency_____Name of Placement Agency_________________________________________________________ City: _______________________ State: ______Social Worker/Intermediary: _______________________________________________________________________________________________

Information about the Birth Parents (at the time of Separation) Birthmother Birthfather

Name(s)

Maiden Name XXXXXXXXXXXXXXXXXXX

Name signed on Relinquishment/Consent

Birthdate

Birthplace

Name of unwed mother’s home XXXXXXXXXXXXXXXXXXX

Marital Status

Religion

Education

Occupation

Military Branch

Nationality

Description

Other Children

Parent’s Names

Search Status - I am: _____ Searching _____ Found but not contacted _____ Contacted but not reunited _____Reunited

I have: Please check the items you currently have.

Adoptee’s Original Birth Certificate Adoptee’s Amended Birth Certificate

Birthmother’s Birth Certificate Social Security # of Person Sought

Adoption Decree Baptismal Certificate

Adoptee’s Hospital Records Birthmother’s Hospital Records

Birthmother’s Marriage Record Other - Please List

Please list any pertinent information, which may be valuable to your search. (Use a separate sheet if necessary. Please attach copies of any documents, which might aid in your search. (Do not send originals.)

Must mail be sent to you in a plain envelope? Yes _____ No _____

Phone* Daytime ( ) ____________________ Okay to call? __________ Collect? __________

Phone* Evening ( ) ____________________ Okay to call? __________ Collect? __________

* We regret that Long Distant calls must be returned collect. Please indicate above which number you would prefer we use if we need to contact you. If you would prefer we NOT identify ourselves as PA Adoption Connection, please supply a name we can use.

Include membership fee with your registration form. This form MUST be returned for placement of your information into the computerized registry.

I have enclosed:

$30 FOR MY FIRST YEAR MEMBERSHIP __________ $20 FOR A ONE YEAR NEWSLETTER SUBSCRIPTION __________

A CONTRIBUTION IN THE AMOUNT OF ___________ (Newsletter included in yearly membership fee)

$30 FOR MY ANNUAL RENEWAL ___________ $15 FOR A COPY OF THE SEARCH GUIDELINES AS A NON-MEMBER

TOTAL ENCLOSED: ______________________

*** PLEASE MAKE CHECKS OR MONEY ORDERS PAYABLE TO PAC OR PA ADOPTION CONNECTION

PA ADOPTION CONNECTION IS FUNDED SOLELY THROUGH MEMBERSHIP AND DONATIONS. YOUR DONATION WILL ASSIST PAC IN CONTINUING ITS WORK. THANK YOU.

I, the undersigned, hereby give my permission to PAC to release this vital information to the person(s) for whom this search is conducted. I understand this permission is necessary for verification of identity, and my relationship to the missing person.

______________________________________________________________ ___________________________

Signature Date

Who referred you or How Did you learn about PA Adoption Connection of Western PA (PAC)? __________________________________________

I would like to participate in the following: (You don’t have to be local)

_____ Search _____Public Relations _____Fund Raising _____ Newsletter _____ Legislative/Legal Reform

_____ Adoptee Support _____ Birthparent Support _____ Community Outreach/Education _____ General Volunteer

“In all of us there is a hunger, marrow deep to know our heritage.....

Without this enriching knowledge, there is a hollow yearning.

No matter what our attainments in life,

there is still a vacuum, an emptiness,

and the most disquieting loneliness...... “ Alex Haley

Note: Please provide a self addressed stamped envelope so that the search guidelines can me mailed to you promptly. This requires two stamps

Return to PAC Home Page



	PA ADOPTION CONNECTION 898 High Point Road, Fort Hill, PA 15540 (814) 395-3938 E-mail: Gshay@aol.com MEMBERSHIP REGISTRATION (All information is confidential.) PLEASE complete this form and return it to the above address in order to have your name and search information entered in the PAC computerized registry and mailing list. Member Information: Full Name:__________________________________________________________ Birth Date: _____________________________________________ Address: ___________________________________________________________ Social Security No.: ______________________________________ City: ______________________________________________________________ State:_______________ Zip Code:__________________________ Home phone:(______)________________________ Work Phone: (______)________________________ E-mail: ______________________________ I am: (please circle your choice) Adoptee Birthparent Adoptive Parent Sibling Other____________________________________________ Information about the child: Child is: Male _____ Female _____Birth Date: (Month/Day/Year: _________________________________ Time:_____________ AM PM Birth Weight: _________ lb _________ozHospital (Birth Place): __________________________________________________ Attending Physician: ________________________________City of Birth: ________________________________________________ County_____________________________________ State:___________Name Given at Birth: _____________________________________________________________________________________________________Name Given at Adoption: __________________________________________________________________________________________________Birth Certificate #s — File #:__________________________________________________________________________Was this a plural birth?: _____________ How many females?: ________ How many males?: ________Court of Jurisdiction ______________________________________ City: ____________________ County:_______________________ State: ____Attorney of Record: ___________________________________________________________ Date of Final Decree: _________________________Adoption Decree #: ____________________________________ Was this adoption: Private______ By an Agency_____Name of Placement Agency_________________________________________________________ City: _______________________ State: ______Social Worker/Intermediary: _______________________________________________________________________________________________ Information about the Birth Parents (at the time of Separation) Birthmother Birthfather Name(s) Maiden Name XXXXXXXXXXXXXXXXXXX Name signed on Relinquishment/Consent Birthdate Birthplace Name of unwed mother’s home XXXXXXXXXXXXXXXXXXX Marital Status Religion Education Occupation Military Branch Nationality Description Other Children Parent’s Names Search Status - I am: _____ Searching _____ Found but not contacted _____ Contacted but not reunited _____Reunited I have: Please check the items you currently have. Adoptee’s Original Birth Certificate Adoptee’s Amended Birth Certificate Birthmother’s Birth Certificate Social Security # of Person Sought Adoption Decree Baptismal Certificate Adoptee’s Hospital Records Birthmother’s Hospital Records Birthmother’s Marriage Record Other - Please List Please list any pertinent information, which may be valuable to your search. (Use a separate sheet if necessary. Please attach copies of any documents, which might aid in your search. (Do not send originals.) Must mail be sent to you in a plain envelope? Yes _____ No _____ Phone* Daytime ( ) ____________________ Okay to call? __________ Collect? __________ Phone* Evening ( ) ____________________ Okay to call? __________ Collect? __________ * We regret that Long Distant calls must be returned collect. Please indicate above which number you would prefer we use if we need to contact you. If you would prefer we NOT identify ourselves as PA Adoption Connection, please supply a name we can use. Include membership fee with your registration form. This form MUST be returned for placement of your information into the computerized registry. I have enclosed: $30 FOR MY FIRST YEAR MEMBERSHIP __________ $20 FOR A ONE YEAR NEWSLETTER SUBSCRIPTION __________ A CONTRIBUTION IN THE AMOUNT OF ___________ (Newsletter included in yearly membership fee) $30 FOR MY ANNUAL RENEWAL ___________ $15 FOR A COPY OF THE SEARCH GUIDELINES AS A NON-MEMBER TOTAL ENCLOSED: ______________________ *** PLEASE MAKE CHECKS OR MONEY ORDERS PAYABLE TO PAC OR PA ADOPTION CONNECTION PA ADOPTION CONNECTION IS FUNDED SOLELY THROUGH MEMBERSHIP AND DONATIONS. YOUR DONATION WILL ASSIST PAC IN CONTINUING ITS WORK. THANK YOU. I, the undersigned, hereby give my permission to PAC to release this vital information to the person(s) for whom this search is conducted. I understand this permission is necessary for verification of identity, and my relationship to the missing person. ______________________________________________________________ ___________________________ Signature Date Who referred you or How Did you learn about PA Adoption Connection of Western PA (PAC)? __________________________________________ I would like to participate in the following: (You don’t have to be local) _____ Search _____Public Relations _____Fund Raising _____ Newsletter _____ Legislative/Legal Reform _____ Adoptee Support _____ Birthparent Support _____ Community Outreach/Education _____ General Volunteer “In all of us there is a hunger, marrow deep to know our heritage..... Without this enriching knowledge, there is a hollow yearning. No matter what our attainments in life, there is still a vacuum, an emptiness, and the most disquieting loneliness...... “ Alex Haley Note: Please provide a self addressed stamped envelope so that the search guidelines can me mailed to you promptly. This requires two stamps Return to PAC Home Page