Académique Documents
Professionnel Documents
Culture Documents
DOB
I II
STAFF
COUNTRY
STATE
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
MALE
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?_______
YES
NO
Their Name(s)_________________________
BY AN AGENCY
SOCIAL WORKER/INTERMEDIARY_________________
Including all info you know is very important. It helps ISRR determine relationships. Please enter everything you have. Update ISRR when you acquire additional data. Get your non-identifying info from state or agency. Click on "Get More Info" at www.isrr.net for guidelines.
Birth Mother
NAME(S) Maiden Name
Birth Father
MARITAL STATUS
RELIGION EDUCATION OCCUPATION
PARENT'S NAMES
-- To help ISRR use contributions wisely, please keep your address, phone numbers & email current and notify ISRR if you are reunited --
I, the undersigned, 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. I understand this permission is necessary to activate registration, facilitate contact and for verification of identity, and my relationship to that person or persons.
X Signature Required____________________________________________________________Date_____________________
ALTERNATIVE ADDRESS AND/OR PHONE______________________________________________________________________ "THIS IS YOUR REGISTRY - 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, SIGN AND MAIL THIS FORM TO: ISRR, P.O. Box 371179, Las Vegas, NV 89137
ISRR will notify you only when a match is made. If you wish confirmation that your form has been received, include a self-addressed stamped envelope with this registration or update. Please do not send anything that requires signatures, or for volunteers to wait in line at the post office. Thank You.
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.
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, marrow-deep, to know our heritage, to know who we are --and where we have come from. Without this enriching knowledge, there is a hollow yearning, there is the most disquieting --- loneliness. " 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. THANK YOU!