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Application for Adoption Registration (Spoken County)

If you want to become registered as an adoption candidate, you have to complete and send this registration form. Make sure to accurately provide all of the required information in the form.

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Center for Health Statistics	 	P.O. Box 9709	 	Olympia, WA  98507	-9709	 	360	-236	-4300	 Select option 3, 	then option 2	 	Adoptions@doh.wa.gov	 	 	
  	
                                                                                                                             	                                                                                                   	 	 	      	DOH 422	-040 	March	 201	5 	
 	
APPLICATION FOR ADOPTION REGISTRATION	 	
 
 Complete in ink	 	
Child 	– Original Birth Certificate Information	 	
 Child’s First Name	 	  	
 Child’s Date of Birth	 	           	 MM             /            DD              /           YYYY	 	 Middle Name	 	
 
 	
 City of Birth	 	
 Last Name	 	
 
 	
 State of Birth 	(Country, 	if born outside the United States	) 	
 Name	 of Hospital or Location where child was b	orn	 	   	
 Sex	 	           	  Female	 	     	 Male	 	
 Mother	/Parent	 Name 	 	                            	First Name	     	                                                   	Full 	Middle	 Name                                                      Birth/Maiden Last Name	 	 Father	/Parent	 Name	, if k	nown	 	                            	First Name	     	                                                   	Full 	Middle	 Name                                                      Birth/Maiden Last Name	 	
Adoptive Parent(s)	 	This	 information	 is required	 and 	will be used	 to create a new birth certificate even if one parent is the 	birth	 parent	 	 Mother	/Parent	 Name 	or Other 	Parent	  	                             	First Name	     	                                                   	Full 	Middle	 Name                                                      Birth/Maiden Last Name	 	 Mother	/Parent	 Date of Birth	 	        	MM             /      	      	DD              /           YYYY	 	
 State of Birth (Country, if born outside the United States)	 	
 Father	/Parent	 Name 	or Other Parent	 (before first m	arriage	) 	                             	First Name	     	                                                   	Full 	Middle	 Name                                                      Birth/Maiden Last Name	 	 Father	/Parent	 Date of Birth 	 	       	MM             /            DD              /           YYYY	 	
 State of Birth (Country, if born outside the United States)	 	
Child’s Name After Adoption	 	
 Child’s New First Name	 	 
 	
 Child’s New Middle Name	 	 Child’s New Last Name	 	
Legal Information	 	
 
 	  Step	 Parent	 	
 
 	  Single Parent	 	
 
 	  Married Couple 	 	
  
 	 Domestic Partnership	 	
 Attorney’s Name 	(First/Middle/Last)	 	  	
 Attorney’s Phone Number	 	  (           	)              	                       	 	
 Attorney’s  Street Address	 	
 	
 Attorney’s Email address	 	
 	
 City	 	
 	
 State	 	 Zip	 	
 Final Date of Decree 	 	     MM	    /    	DD	     	/     	YYYY	 	
 County of Decree	 	 Cause Number	 	
Mailing Address	 	
 Mail	 Certified Copy of n	ew Birth Certificate to:	 	 Current Parent(s) Mailing Address	: 	
 Name	 	  	
 Name	 	 	
 Address	 	  	
 Address	 	 	
 City, State, Zip	 	  	
 City, State, Zip
Next: Adoption Data Card Previous: Affidavit of Birth
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