Please place this consent form in my birth child’s adoption file:

I, __________________________________________, as biological mother/father of ____________________born on ______________

Consent_______ Do Not Consent_______

to the aforementioned child, upon reaching adulthood being allowed to

inspect the adoption records pertaining to him/her. I understand that under

current law, personal contact information will not be released by the Circuit

Court or the Cabinet for Health and Family Services without a court order.

Also, I

Consent _______ Do Not Consent_______

to the child having personal contact with me upon reaching adulthood. I understand that under current law, personal contact informatiln will not be released by the Circuit Court or the Cabinet for Health and Family Services without a court order.

I understand that copies of this document will be filed in the records of the Cabinet for Health and Family Services and in the circuit court records of the adoption. I also understand that this consent/denial of consent is valid until recoked or altered by me.

Name: ______________________________________________________

Address: ____________________________________________________

City/State/Zip:________________________________________________

Phone Number with area code: __________________________________

E-mail address: ______________________________________________

Social Security number: _______________________________________

Signature and date:___________________________________________