Please use this form to register information about an adopted child. Please provide as much information as you know. Please be sure to complete the fields marked with an asterisk.

I. Adoptee's Information

*Adoptee's Current Name
Last First Middle

Adoptee's Name Recorded on Original Birth Certificate
Last First Middle

Date of Birth (MM/DD/YY) Gender Male Female

Place of Birth

County City/Municipality State Hospital (if known)

County Where Adoption Was Finalized
City/County State Date Adoption was Finalized

Birth Parent's Name
Last First Middle

Date of Birth
MM/DD/YY

Birth Parent's Name
Last First Middle

Date of Birth
MM/DD/YY

Birth Parent's Address (Street, City, State, Zip)

Adoptive Parent's Name
Last First Middle

Date of Birth
MM/DD/YY

Adoptive Parent's Name
Last First Middle

Date of Birth
MM/DD/YY

Adoptive Parent's Address (Street, City, State, Zip)

II. Agency Information

*Agency Name

*Caseworker (full name)

Agency Mailing Address

*E-Mail

City

State

Zip

*Telephone # (e.g. XXX-XXX-XXXX or
(XXX) XXX-XXXX)

Fax

III. Child's Records

Records Uploaded to DPW/OCYF

Child Profile OR Child's Social Summary

Child's Medical Records/Medical Information

File(s) must be in .pdf format, not to exceed 20mb. You may upload more than one file by holding down the Control key when you select a file or by clicking the Browse button multiple times. Please allow all file uploads to finish before submitting.

I verify that the above infromation is accurate and complete to the best of my knowledge and belief and submitted as true and correct under penalty of law (Section 4904 of the Pennsylvania Crimes Code).

*Name of submitter

*Date

If the agency information for submitter is different than the information provided in Section II, please provide the submitter's agency information below.

Agency Name

Caseworker (full name)

Agency Mailing Address

E-Mail

City

State

Zip

Telephone #

Fax

Please validate the caption below.