Request for Services - Children's Home Society of Florida

Request for Services

* Name:
* Email address:
I am:	Adoptee Birth parent Adoptive parent Sibling Other If other, please designate
Current address:
Current city:
Current state:
Current zip:
Telephone (home):	() -Second partThird part
Telephone (work):	() -Second partThird part
Cell:	() -Second partThird part
Date of birth:	Date and time
Adoptive parent:
Adoptee's adopted name:
Birth parent name:
DOB:	Date and time
Residence (city) in Florida at time of adoption service:
DOB of adoptee (child placed for adoption):	Date and time
Sex:
Type of service requested (check all that apply):
	Update of information for archived adoption record
	Non-Identifying background information
	Non-Identifying medical background information
	Search services/contact for updated information
	Possible reunion services
	Other:

Comments:
	I understand that CHS, in providing this service, will furnish available information which in the agency's opinion is appropriate to this request. I further understand that all records are the property of CHS and that I will not have access to them.

* Required fields.

How To Contact Us
Please do not hesitate to call or write us if you have any questions about the search process. Our professional staff is always pleased to help you in any way possible.

You may mail all correspondence, applications and fees to:
Adoption Archives Unit
Children's Home Society of Florida
P.O. Box 5616
Jacksonville, FL 32247
Telephone: (904) 493-7780
Fax: (904) 348-2848

No clients shall be discriminated against on the basis of race, color, religion, sex, age, national origin, disability, sexual orientation, or any other characteristic protected by federal, state or local law. Clients needing accommodations for a disability and/or clients with special communications needs should contact their Children’s Home Society of Florida worker or make their request for accommodation at the time of admission into a Children’s Home Society of Florida program.

CHILDREN'S HOME SOCIETY OF FLORIDA, REGISTRATION #CH180, IS REGISTERED WITH THE STATE UNDER THE SOLICITATION OF CONTRIBUTIONS ACT. A COPY OF THE OFFICIAL REGISTRATION AND FINANCIAL INFORMATION MAY BE OBTAINED FROM THE DIVISION OF CONSUMER SERVICES BY CALLING TOLL-FREE (800-435-7352) WITHIN THE STATE. REGISTRATION DOES NOT IMPLY ENDORSEMENT, APPROVAL OR RECOMMENDATION BY THE STATE.