ࡱ> y|tuvwx yGbjbj7171 .U[cU[cZO +++++$OOOPZ|\O?4P/(000K1b79=======$!AC=+:K1K1::=++004?<<<:F+0+0=<:=<<`==0/c:x==?0?=WD;WD=WD+=,::<:::::==<:::?::::WD::::::::: : New Jersey Department of Health Vital Statistics and Registry PO Box 370 Trenton, NJ 08625-0370NEW RECORDS SYSTEM FOR BIRTH PARENTS CONTACT PREFERENCEAA birth parent of an adopted person may submit a Contact Preference document to the State Registrar indicating his or her preference regarding contact with the adopted individual. The birth parent may change his or her preference at any time by submitting a revised Contact Preference document to the State Registrar. We need the following information in order to find and match your request with our existing files. If you fail to provide complete and accurate information, then we may be unable to accept and process your request. NOTE: You must also complete and submit a Family History Information form, which includes medical, cultural and social history information, in order for your Contact Preference form to be accepted for filing.ORIGINAL BIRTH CERTIFICATE INFORMATIONPlease provide complete and accurate information. While the Department will diligently search its files for an adoption record that matches your request, it does not warrant, promise or guarantee that it will be able to locate an adoption record that matches the information you provide in your request.CHILDS INFORMATIONChilds FIRST Name on Childs Original Birth Certificate: FORMTEXT      Child s MIDDLE Name on Child s Original Birth Certificate: FORMTEXT      Child s LAST Name on Child s Original Birth Certificate: FORMTEXT      Suffix: FORMDROPDOWN Note: If you are unsure of the exact date of the child's birth, please enter your best estimate.Child s Date of Birth:  FORMTEXT __ __ / __ __ / __ __ __ __[ FORMTEXT  ] Actual [ FORMTEXT  ] EstimateSex:[ FORMTEXT  ] Male [ FORMTEXT  ] FemaleCountry of Birth: FORMTEXT      State of Birth: FORMTEXT      County of Birth: FORMTEXT      Municipality of Birth: FORMTEXT      MOTHER S INFORMATIONMother s FIRST Name on Child s Original Birth Certificate:  FORMTEXT      Mother s MIDDLE Name on Child s Original Birth Certificate:  FORMTEXT      Mother s LAST Name on Child s Original Birth Certificate:  FORMTEXT      Mother s Date of Birth:  FORMTEXT __ __ / __ __ / __ __ __ __FATHER S INFORMATIONFather s FIRST Name on Child s Original Birth Certificate:  FORMTEXT      Father s MIDDLE Name on Child s Original Birth Certificate:  FORMTEXT      Father s LAST Name on Child s Original Birth Certificate:  FORMTEXT      Father s Date of Birth:  FORMTEXT __ __ / __ __ / __ __ __ __BIRTH PARENT INFORMATIONNOTE: The birth parent information requested below is for processing purposes and will not be released to a requester if you wish to retain your privacy at this time.Birth Parents Current First Name: FORMTEXT      Birth Parent s Current Middle Name: FORMTEXT      Birth Parent s Current Last Name: FORMTEXT      Birth Parent s Date of Birth: FORMTEXT __ __ / __ __ / __ __ __ __Birth Parent s Relationship to Child: [ FORMTEXT  ] Mother [ FORMTEXT  ] FatherPhone 1: FORMTEXT      [ FORMTEXT  ] Home [ FORMTEXT  ] Mobile [ FORMTEXT  ] WorkPhone 2: FORMTEXT      [ FORMTEXT  ] Home [ FORMTEXT  ] Mobile [ FORMTEXT  ] WorkPhone 3: FORMTEXT      [ FORMTEXT  ] Home [ FORMTEXT  ] Mobile [ FORMTEXT  ] WorkEmail Address: FORMTEXT      Mailing Address: FORMTEXT       FORMTEXT      City: FORMTEXT      State: FORMTEXT      Zip: FORMTEXT      The Contact Preference form is only an expression of the birth parent's wishes regarding contact with the adoptee. There is no law requiring the adoptee to follow the preference selected by the birth parent on the form.BIRTH PARENTS CONTACT PREFERENCEState your preference about contact with the adopted child. Note: Selection is required.A.  FORMCHECKBOX  I would like to be contacted directly. I have provided the required contact preference information and an updated Family History Information document and am submitting them to the State Registrar as set forth in this document. (Complete required information on the previous page.)B.  FORMCHECKBOX  I would prefer to be contacted only through an intermediary. I have provided the required contact preference information and an updated Family History Information document. I am submitting both to the State Registrar as set forth in this document. I have named the listed individual to act as an intermediary. (Complete the following required information.)Name of Individual or Agency: FORMTEXT      Mailing Address: FORMTEXT       FORMTEXT      City: FORMTEXT      State: FORMTEXT      Zip: FORMTEXT      Phone 1: FORMTEXT       FORMCHECKBOX  Home  FORMCHECKBOX  Mobile  FORMCHECKBOX  WorkPhone 2: FORMTEXT       FORMCHECKBOX  Home  FORMCHECKBOX  Mobile  FORMCHECKBOX  WorkPhone 3: FORMTEXT       FORMCHECKBOX  Home  FORMCHECKBOX  Mobile  FORMCHECKBOX  WorkEmail Address: FORMTEXT      C.  FORMCHECKBOX  I would prefer to not be contacted at this time. If I decide later that I would like to be contacted, I will submit a revised Contact Preference form to the State Registrar. While I do not wish to be contacted at this time, I have completed the Family History Information form and am submitting it to the State Registrar. Additionally, I understand that because I have indicated a no contact preference I must update the Family History Information form and submit it to the State Registrar every ten (10) years until I reach the age of forty (40) and every five (5) years thereafter.By signing, I certify that I am the birth parent of the adoptee and, that, to the best of my knowledge, the information I am supplying is correct and accurate. I understand that if I falsely represent that I am the birth parent of the adoptee on this form, then I may be subject to penalties pursuant to N.J.S.A. 26:8-69.Signature of Birth Parent:Date: FORMTEXT       New Jersey Department of Health Vital Statistics and Registry PO Box 370 Trenton, NJ 08625-0370NEW RECORDS SYSTEM FOR BIRTH PARENTS FAMILY HISTORY INFORMATIONBORIGINAL BIRTH CERTIFICATE INFORMATIONPlease provide complete and accurate information. While the Department will diligently search its files for an adoption record that matches your request, it does not warrant, promise or guarantee that it will be able to locate an adoption record that matches the information you provide in your request.CHILDS INFORMATIONChilds FIRST Name on Childs Original Birth Certificate:  REF childoriginalfname \h  Childs MIDDLE Name on Childs Original Birth Certificate:  REF childoriginalmname \h  Childs LAST Name on Childs Original Birth Certificate:  REF childoriginallname \h  Suffix:  REF childoriginalsuffix \h  Childs Date of Birth:  REF childdob \h __ __ / __ __ / __ __ __ __[ REF childdobactual \h  ] Actual [ REF childdobestimate \h  ] EstimateSex:[ REF childsexmale \h  ] Male [ REF childsexfemale \h  ] FemaleCountry of Birth: REF childbirthcountry \h  State of Birth: REF childbirthstate \h  County of Birth: REF childbirthcounty \h  Municipality of Birth: REF childbirthmunic \h  MOTHERS INFORMATIONMothers FIRST Name on Childs Original Birth Certificate:  REF momfnameoncert \h  Mothers MIDDLE Name on Childs Original Birth Certificate:  REF mommnameoncert \h  Mothers LAST Name on Childs Original Birth Certificate:  REF momlnameoncert \h  Mothers Date of Birth:  REF momdoboncert \h __ __ / __ __ / __ __ __ __FATHERS INFORMATIONFathers FIRST Name on Childs Original Birth Certificate:  REF dadfnameoncert \h  Fathers MIDDLE Name on Childs Original Birth Certificate:  REF dadmnameoncert \h  Fathers LAST Name on Childs Original Birth Certificate:  REF dadlnameoncert \h  Fathers Date of Birth:  REF daddoboncert \h __ __ / __ __ / __ __ __ __BIRTH PARENT INFORMATIONNOTE: The birth parent information requested below is for processing purposes and will not be released to a requester if you wish to retain your privacy at this time.Birth Parents Current First Name: REF bparentcurrentfname \h  Birth Parents Current Middle Name: REF bparentcurrentmname \h  Birth Parents Current Last Name: REF bparentcurrentlname \h  Birth Parents Date of Birth: REF bparentdob \h __ __ / __ __ / __ __ __ __Birth Parents Relationship to Child: [ REF birthparentmom \h  ] Mother [ REF birthparentdad \h  ] FatherPhone 1: REF bparentphone1 \h  [ REF phone1home \h  ] Home [ REF phone1mobile \h  ] Mobile [ REF phone1work \h  ] WorkPhone 2: REF bparentphone2 \h  [ REF phone2home \h  ] Home [ REF phone2mobile \h  ] Mobile [ REF phone2work \h  ] WorkPhone 3: REF bparentphone3 \h  [ REF phone3home \h  ] Home [ REF phone3mobile \h  ] Mobile [ REF phone3work \h  ] WorkEmail Address: REF bparentemail \h  Mailing Address: REF bparentaddress1 \h   REF bparentaddress2 \h  City: REF bparentcity \h  State: REF bparentstate \h  Zip: REF bparentzip \h  BIRTH PARENT DEMOGRAPHIC INFORMATIONYour Current Age: FORMTEXT      Eye Color: FORMDROPDOWN Blood Type: FORMDROPDOWN Height (inches): FORMTEXT      Hair Color FORMDROPDOWN Primary Language Spoken: FORMTEXT      Weight (lbs.) FORMTEXT      Race: FORMDROPDOWN Nationality (Citizenship): FORMTEXT      Religion: FORMTEXT      Skin Color: FORMDROPDOWN Highest Level of Education: FORMDROPDOWN Ethnic Background: FORMDROPDOWN Your Place of Birth:Country: FORMTEXT      State: FORMTEXT      City: FORMTEXT      BIOLOGICAL INFORMATION ON DECEASED FAMILY MEMBERSList your family members who have passed away, age at death, and cause of death:Relationship*: FORMDROPDOWN Age at Death: FORMTEXT      Cause of Death: FORMTEXT      Relationship*: FORMDROPDOWN Age at Death: FORMTEXT      Cause of Death: FORMTEXT      Relationship*: FORMDROPDOWN Age at Death: FORMTEXT      Cause of Death: FORMTEXT      Relationship*: FORMDROPDOWN Age at Death: FORMTEXT      Cause of Death: FORMTEXT      Relationship*: FORMDROPDOWN Age at Death: FORMTEXT      Cause of Death: FORMTEXT      Relationship*: FORMDROPDOWN Age at Death: FORMTEXT      Cause of Death: FORMTEXT      Relationship*: FORMDROPDOWN Age at Death: FORMTEXT      Cause of Death: FORMTEXT      Relationship*: FORMDROPDOWN Age at Death: FORMTEXT      Cause of Death: FORMTEXT      Relationship*: FORMDROPDOWN Age at Death: FORMTEXT      Cause of Death: FORMTEXT      Relationship*: FORMDROPDOWN Age at Death: FORMTEXT      Cause of Death: FORMTEXT      Relationship*: FORMDROPDOWN Age at Death: FORMTEXT      Cause of Death: FORMTEXT      Relationship*: FORMDROPDOWN Age at Death: FORMTEXT      Cause of Death: FORMTEXT      *Relationship choices: " Mother " Son " Maternal Grandmother " Paternal Grandmother " Sister " Aunt " Father Daughter Maternal Grandfather Paternal Grandfather Brother Uncle Other Biological ParentMEDICAL HISTORYFor each of the medical conditions listed below, please check the appropriate column indicating whether you or any of your blood relatives (mother, father, sisters, brothers, grandparents, aunts, or uncles) or any other of your children have the condition(s) listed. Comments should include information on age of onset or diagnosis, treatments received or hospitalizations for condition, etc. Note: All fields under this section are required.Heart and Blood VesselsMedical ConditionResponseCommentsCongenital Heart Defect FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      Congestive Heart Failure FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      Atherosclerosis FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      Hypertension (High Blood Pressure) FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      Stroke FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      Heart Attack FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      Other Cardiovascular Problems FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      Brain and NervesMedical ConditionResponseCommentsCerebral Palsy FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      Seizures, Convulsions or Epilepsy FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      LungsMedical ConditionResponseCommentsChronic Bronchitis FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      Emphysema FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      Asthma FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      Hay Fever or Other Allergies; 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$If^akd$$IfTH4F )    4 Haf4T$$If$If $If^;kdu$$IfTH4)0*4 Haf4Tc|cc VX:Kkd$$IfTH4)0*  &4 Haf4p &T$$Ifakd$$IfTH4 F )    4 Haf4T$If  $IfMTEXT      MEDICAL HISTORY, CONTINUEDFor each of the medical conditions listed below, please check the appropriate column indicating whether you or any of your blood relatives (mother, father, sisters, brothers, grandparents, aunts, or uncles) or any other of your children have the condition(s) listed. Comments should include information on age of onset or diagnosis, treatments received or hospitalizations for condition, etc. Note: All fields under this section are required.BLOOD DISORDERMedical ConditionResponseCommentsSickle Cell Anemia or Tay-Sachs Disease FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      JOINTS / SKELETONMedical ConditionResponseCommentsScoliosis  FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      Any Other Malformations FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      ENDOCRINE (GLANDS)Medical ConditionResponseCommentsThyroid Disorder FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      Diabetes FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      Other Hormonal Disorder FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      PSYCHOSOCIALMedical ConditionResponseCommentsSchizophrenia, Bipolar Disorder, or Chronic Depression FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      Alcoholism, Drug Addiction orTobaccoUse FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      Anorexia or Bulimia FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      Other Mental or Emotional Illnesses FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      SKIN DISORDERSMedical ConditionResponseCommentsEczema or Other Skin Conditions FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      DEVELOPMENTALMedical ConditionResponseCommentsLearning Disability FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      Mental or Physical Development Deficiencies FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      Autism Spectrum FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      MEDICAL HISTORY, CONTINUEDFor each of the medical conditions listed below, please check the appropriate column indicating whether you or any of your blood relatives (mother, father, sisters, brothers, grandparents, aunts, or uncles) or any other of your children have the condition(s) listed. Comments should include information on age of onset or diagnosis, treatments received or hospitalizations for condition, etc. Note: All fields under this section are required.NEUROLOGICALMedical ConditionResponseCommentsBlindness, Glaucoma or Other Visual Problems FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      Deafness or Other Ear Problems FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      Speech Problem FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      Muscular Dystrophy FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      GENETICMedical ConditionResponseCommentsClub Foot, Cleft Lip or Palate FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      Down s Syndrome FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      MOTOR DEFICIENCIESMedical ConditionResponseCommentsMultiple Sclerosis FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      Other Paralysis or Crippling Disorder FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      CANCERMedical ConditionResponseCommentsCancer (Breast, Ovarian, Cervical, Prostate, etc.) FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      Tumors FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      Cystic Fibrosis FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      Huntington s Disease FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      MEDICAL HISTORY, CONTINUEDFor each of the medical conditions listed below, please check the appropriate column indicating whether you or any of your blood relatives (mother, father, sisters, brothers, grandparents, aunts, or uncles) or any other of your children have the condition(s) listed. Comments should include information on age of onset or diagnosis, treatments received or hospitalizations for condition, etc. Note: All fields under this section are required.OTHER CONDITIONSMedical ConditionResponseCommentsAny Other Conditions You or Others in Your Family May Have FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known  FORMCHECKBOX  Yes (Relative) FORMTEXT      SOCIAL/CULTURAL BACKGROUNDCultural BackgroundResponseCommentsPrescription Drugs Taken During Pregnancy FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known FORMTEXT      Non-Prescription Drugs Taken During Pregnancy FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known FORMTEXT      Alcohol Use During Pregnancy FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known FORMTEXT      Amphetamines or Barbiturates Used During Pregnancy FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known FORMTEXT      Are birth parents related to each other (other than by marriage)? FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known FORMTEXT      Were there special circumstances surrounding conception, pregnancy or delivery? FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known FORMTEXT      Can you provide information about the mother's reproductive life (for example, the age at first menses; age at menopause, miscarriages or fertility issues)? FORMCHECKBOX  No  FORMCHECKBOX  Yes (Self)  FORMCHECKBOX  Not Known FORMTEXT      Please provide any additional information related to the Medical / Social / Cultural History section: FORMTEXT      By signing, I certify that I am the birth parent of the adoptee and, that, to the best of my knowledge, the information I am supplying is correct and accurate. I understand that if I falsely represent that I am the birth parent of the adoptee on this form, then I may be subject to penalties pursuant to N.J.S.A. 26:8-69.Signature of Birth Parent:Date: FORMTEXT           REG-36A For questions or additional Information: JAN 17 www.nj.gov/health/vital ( 866-649-8726, EXT. 582 Page  PAGE 1 of 3. REG-36B For questions or additional Information: JAN 17 www.nj.gov/health/vital ( 866-649-8726, EXT. 582 Page  PAGE 7 of 7.  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