RN

S

DOB

FOR OFFICE USE ONLY

I II

STAFF

COUNTRY

STATE

MAIL TO: ISRR, P.O. BOX 371179, LAS VEGAS, NV 89137
DO NOT WRITE ABOVE THIS LINE

Official Registration Form -- Confidential --

COMPLETE BOTH PAGES of this form, use BLACK ink, THEN PRINT, SIGN & MAIL
Please read the guidelines on page 4. This will help you fill out the form correctly.
This registration is my FIRST ENTRY
I AM THE: ADOPTEE/CHILD
BIRTH PARENT

an UPDATE
OTHER: (explain)_____________________________

BIRTH SIBLING

PRESENT NAME:____________________________________________________________ REFERRED BY: _____________________ ADDRESS:________________________________CITY:____________________STATE:______ZIP:__________
TELEPHONE NUMBER(S)

HOME: (_____) ______-___________

SOCIAL SECURITY #: __________-______-_________ E-MAIL: ______________________________________
FEMALE

WORK: (_____) ______-__________

Information About the CHILD

MALE

BIRTH DATE (Month/Day/Year)________________ TIME________ AM

PM

BIRTH WEIGHT______lb_____oz

HOSPITAL (Birth Place) _________________________ ATTENDING PHYSICIAN (Or Other)___________________ CITY OF BIRTH_______________________COUNTY_______________STATE_________ COUNTRY___________ NAME GIVEN AT BIRTH__________________________________________________________________________ NAME GIVEN AT ADOPTION______________________________________________________________________ ADOPTIVE PARENT'S NAMES_____________________________________________________________________ BIRTH CERTIFICATE #'s -- File #_________________________________Registrar #_________________________ IF THIS WAS A PLURAL BIRTH (Twins/Triplets, etc.), How many MALES?_________How many FEMALES?_______

Were they separated by adoption?

YES

NO

Their Name(s)_________________________

COURT OF JURISDICTION____________________________CITY________________________STATE___________ ATTORNEY OF RECORD______________________________DATE OF FINAL DECREE______________________

This adoption was -- PRIVATE

BY AN AGENCY

SOCIAL WORKER/INTERMEDIARY_________________

NAME OF PLACEMENT AGENCY_______________________CITY________________________STATE_________

INTERNATIONAL SOUNDEX REUNION REGISTRY, Inc.

.net for guidelines. Click on "Get More Info" at www. I understand this permission is necessary to activate registration.isrr. NV 89137 ISRR will notify you only when a match is made.O. Las Vegas.To help ISRR use contributions wisely. Update ISRR when you acquire additional data. phone numbers & email current and notify ISRR if you are reunited -- I. please keep your address. facilitate contact and for verification of identity. Thank You.YOUR CONTRIBUTION IS TAX DEDUCTIBLE" Registration remains free because of the generosity of those we serve ~ ISRR is a non-profit 501(c)3 tax exempt corporation ©1993-2009 International Soundex Reunion Registry WE LOOK FORWARD TO SERVING YOU! PLEASE PRINT. Box 371179. If you wish confirmation that your form has been received. or for volunteers to wait in line at the post office. the undersigned. P.Information About the BIRTH PARENTS (at time of separation): Including all info you know is very important. Birth Mother NAME(S) Maiden Name Birth Father Used At time of Birth Signed on Relinquishment/Consent BIRTH DATE BIRTH PLACE Age At Birth Age At Birth MARITAL STATUS RELIGION EDUCATION OCCUPATION MILITARY BRANCH ANCESTRY DESCRIPTION OTHER CHILDREN HEIGHT WEIGHT HAIR EYES HEIGHT WEIGHT HAIR EYES PARENT'S NAMES REMARKS: (use a separate sheet if needed) -. Get your non-identifying info from state or agency. include a self-addressed stamped envelope with this registration or update. Please do not send anything that requires signatures. SIGN AND MAIL THIS FORM TO: ISRR. Please enter everything you have. X Signature Required____________________________________________________________Date_____________________ ALTERNATIVE ADDRESS AND/OR PHONE______________________________________________________________________ "THIS IS YOUR REGISTRY . It helps ISRR determine relationships. hereby give my permission to the International Soundex Reunion Registry to release this vital information to the person(s) for whom this search is conducted. and my relationship to that person or persons.

there is a hollow yearning. " Alex Haley ~ Roots ISRR has been serving families since 1975 ~ Making Matches for Registrants ~ Sharing in Your Reunions Your Contributions help us help you and all the others touched by family separation. because of time given by our dedicated volunteers and contributions given by individuals registering here. It touches the lives of all those registered now. Your generosity matters. When Julie. BOX 371179 • LAS VEGAS. Enclosed please find my contribution of: $______________ CHECK MONEY ORDER Name:_____________________________________________________________ Address:___________________________________________________________ City:_______________________________State:_________Zip:_______________ Please charge my contribution to: VISA MasterCard Discover Credit Card # ______________________________________ Expiration Date: ______________ Signature: ______________________________________ Phone # ______________________ E-Mail:____________________________________________ Please send my receipt by Email: US mail: Donation receipts will serve to confirm the date ISRR received and processed your enclosed registration or update. none of them had ever really expected an end to their search and to experience the joys of the reunions that followed. and long into the future. there is the most disquieting --. a birth mother. many thousands had their dreams come true by simply registering with the Internatiional Soundex Reunion Registry. The ISRR Voluntary Board of Trustees thank you. Make checks payable to: ISRR YES! I want to help. to know our heritage. With this receipt please include any data ISRR has on the state where this registration's birth occurred: Choose One State "In all of us there is a hunger. Won't you please help ensure your registry will continue to serve you and so many others. marrow-deep. was reunited with her daughter. This registry has always been provided without cost to its registrants. You too. Ronald with his father. a cost that seems to increase annually. THANK YOU! "united today for the reunions of tomorrow" your contributions are tax-deductible . Send your contribution today. Since 1975.O.loneliness.INTERNATIONAL SOUNDEX REUNION REGISTRY Mail contributions to ~ ISRR • P. Without this enriching knowledge. are given this same hope and opportunity. All donations are gratefully accepted. Jeffery with his brother and two sisters. to know who we are --and where we have come from. Naturally costs are incurred in the operation and maintenance of your registry.NEVADA 89137• (775) 882-7755 Dear Registrant.