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BIRTH PARENT PREFERENCE FORM

In recognition of the basic right of all persons to access their birth records, Illinois law now provides for the release of original birth certificates to adopted and surrendered persons 21 years of age or older upon request. While many birth parents are comfortable sharing their identities or initiating contact with their birth sons and daughters once they have reached adulthood, Illinois law also recognizes that there may be unique situations where a birth parent might have a compelling reason for not wishing to establish contact with a birth son or daughter or for not wishing to release identifying information that appears on the original birth certificate of a birth son or daughter who has reached adulthood. The Illinois Adoption Registry and Medical Information Exchange (IARMIE) has therefore established this form to allow birth parents whose birth son or daughter was born on or after January 1, 1946, to express their wishes regarding contact and the sharing of identifying information listed on the original birth certificate with an adult adopted or surrendered person who has reached the age of 21.

In selecting one of the five options below, birth parents should keep in mind that the decision to deny an adult adopted or surrendered person access to identifying information on his or her original birth record and/or information about genetically-transmitted diseases is an important one that can impact the adopted or surrendered person's life in many ways. A request for anonymity on this form only pertains to information that is provided to an adult adopted or surrendered person or his or her surviving relatives through the Registry and does not prevent the disclosure of identifying information that may be available to the adoptee through his or her adoptive parents and/or other means available to him or her. Birth parents who would prefer not to be contacted by their surrendered son or daughter are strongly urged to complete both the Non-Identifying Information Section included on the final page of this document and the Medical Questionnaire in order to provide their surrendered son or daughter with the background information they may need to better understand themselves and their origins. Furthermore, since no original birth certificates are released by the IARMIE before an adoptee has reached the age of 21, birth parents are encouraged to take as much time as they need to weigh the options available to them before completing this form. Should you need additional assistance in completing this form, please contact (name and phone number of agency contact person, if applicable) _________________________________ or the Illinois Adoption Registry and Medical Information Exchange at 217- 557-5159.

After careful consideration, I, (insert your name) ______________________________________, have made the following decision regarding contact with my birth son/birth daughter, (insert birth son’s/birth daughter’s name at birth, if applicable) __________________________________, who was born in (insert city/town of birth) ____________________ on (insert date of birth)______________________________ and the release of my identifying information as it appears on his/her original birth certificate when he/she reaches the age of 21, and I have chosen Option _____ (insert A, B, C, D or E, as applicable). I realize that this form must be accompanied by a completed IARMIE application form as well as a Medical Information Exchange Questionnaire or the $15 registration fee. I am also aware that I may revoke this decision at any time by completing a new Birth Parent Preference Form and filing it with the IARMIE. I understand that it is my responsibility to update the IARMIE with any changes to contact information provided below. I also understand that, while preferences regarding the release of identifying information through the Registry are binding unless the law should change in the future, any selection I have made regarding my preferred method of contact is not.

_________________________________________________________________________________________

(Signature/Date)

(Please insert your signature and today’s date above, as well as under your chosen option, A, B, C, D, or E below.)

Option A. I agree to the release of my identifying information as it appears on my birth son’s/birth daughter’s original birth certificate, would welcome direct contact with my birth son/birth daughter when he or she has reached the age of 21 and I wish to be contacted at the following mailing address, email address or phone number:

_________________________________________________________________________________________

(Signature/Date)

Option B. I agree to the release of my identifying information as it appears on my birth son’s/birth daughter’s original birth certificate, would welcome contact with my birth son/birth daughter when he or she has reached the age of 21, but I would prefer to be contacted through the following person (insert name and mailing address, email address or phone number of chosen contact person) _________________________________________________

_________________________________________________________________________________________

(Signature/Date)

Option C. I agree to the release of my name as it appears on my birth son’s/birth daughter’s original birth certificate, would welcome contact with my birth son/birth daughter when he or she has reached the age of 21, but I would prefer to be contacted through the Illinois confidential intermediary program (please call 800-526-9022 for additional information) or through the agency that handled the adoption. (insert agency name, address and phone number, if applicable.)________________________________________________________________________

_________________________________________________________________________________________

(Signature/Date)

Option D. I agree to the release of my name as it appears on my birth son’s/birth daughter’s original birth certificate, but I would prefer not to be contacted by my birth son/birth daughter when he or she has reached the age of 21.

_________________________________________________________________________________________

(Signature/Date)

Option E. I wish to prohibit the release of my (circle ALL applicable options) first name, last name, last known address______________________________________________birth son/birth daughter’s last name (if last name listed is same as mine), as they appear on my birth son’s/birth daughter’s original birth certificate, and do not wish to be contacted by my birth son/birth daughter when he or she has reached the age of 21. If there were any special circumstances that played a role in your decision to remain anonymous which you would like to share with your birth son/birth daughter, please list them in the space provided below (optional)._________________________________________________________________________________

____________________________________________________________________________________________________________

_____________________________________________________________________________________________________________

I understand that, although I have chosen to prohibit the release of my identity on the copy of the original birth certificate released to my birth son/birth daughter, he or she may request that a court-appointed confidential intermediary contact me to request updated medical information and/or confirm my desire to remain anonymous once five years have elapsed since the signing of this form. I also understand that this request for anonymity shall expire upon my death.

___________________________________________________________________________________________________________________

(Signature/Date)

STATE OF______________________

COUNTY OF_____________________

I, a Notary Public, in and for the said county, in the state aforesaid, do hereby certify that ____________________________________________________ personally known to me to be the same person whose name is subscribed to this document appeared before me in person and acknowledged that he/she signed this document under the chosen option as his/her free and voluntary act.

Given under my hand and notarial seal on ___________________________________, ___________ (insert date)

________________________________________________________

SIGNATURE OF NOTARY

Non-Identifying Information Section

I wish to voluntarily provide the following non-identifying information to my surrendered son or daughter:

My age at the time of my child's birth was_____

My race is best described as: _______________________________________________

My height is:_______________

My body type is best described as (circle one): slim, average, muscular, a few extra pounds, more than a few extra pounds

My natural hair color is/was: ______________________________________

My eye color is: _______________________________________________

My religion is best described as: _______________________________________________

My ethnic background is best described as:_________________________________

My educational level is closest to (circle applicable response): completed grammar school, graduated from high school, attended college, earned Bachelor's degree, earned Master's degree, earned PhD.

My occupation is best described as __________________________________________________________________________________________

My hobbies include_______________________________________________________________________________________________________

My interests include_______________________________________________________________________________________________________

My talents include_________________________________________________________________________________________________________

In addition to my surrendered son or daughter, I also am the biological parent of (insert number) _______ boys and (insert number) ________ girls, of whom (insert number)________ are still living.

The relationship between me and my child's birth mother/birth father would best be described as (circle appropriate response): husband and wife,
ex-spouses, boyfriend and girlfriend, casual acquaintances, other (please specify)__________________________________________________________________