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RN

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.

Information About the BIRTH PARENTS (at time of separation):

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

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)

-- 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.

INTERNATIONAL SOUNDEX REUNION REGISTRY


Mail contributions to ~ ISRR P.O. BOX 371179 LAS VEGAS,NEVADA 89137 (775) 882-7755 Dear Registrant, When Julie, a birth mother, was reunited with her daughter, Ronald with his father, Jeffery with his brother and two sisters, none of them had ever really expected an end to their search and to experience the joys of the reunions that followed. Since 1975, many thousands had their dreams come true by simply registering with the Internatiional Soundex Reunion Registry. You too, are given this same hope and opportunity. This registry has always been provided without cost to its registrants, because of time given by our dedicated volunteers and contributions given by individuals registering here. Naturally costs are incurred in the operation and maintenance of your registry, a cost that seems to increase annually. Won't you please help ensure your registry will continue to serve you and so many others. Your generosity matters. It touches the lives of all those registered now, and long into the future. Send your contribution today. All donations are gratefully accepted. The ISRR Voluntary Board of Trustees thank you. Make checks payable to: ISRR YES! I want to help. 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.
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!

"united today for the reunions of tomorrow"


your contributions are tax-deductible

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