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Adoption Information Worksheet

ADOPTION INFORMATION WORKSHEET

Information Regarding Child To Be Adopted

1. Name of child at birth: __________________________________________

2. Name of child after adoption: ____________________________________

3. Sex of child: _______________________

4. Age of child: _______________________

5. Date of birth: _______________________

6. Place of birth: _________________________________________________

7. Hospital: _____________________________________________________

8. Attending physician: ____________________________________________

9. Race of Child: _____________________

10. Property owned by child: _______________________________________________

Remarks: ___________________________________________________

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