Application for adoption information by an adopted child or his or her

Application for adoption information by an
adopted child or his or her adoptive parent/s
Adoption Act 2009 (sections 254 and 256)
Adoption Regulation 2009 (section 11)
The purpose of the application for adoption information by an adopted child or his or her adoptive parent/s form
This form is for use by an adopted child, with the consent of an adoptive parent, or by an adoptive parent/s, to apply for pre-adoption
information about an adopted child.
Identifying information about an adopted child may be released only if written consent is given by both birth parents identified by the
information, and the child’s adoptive parent/s give their consent.
Upon receiving an application for pre-adoption information about a birth parent, from an adopted child, or their adoptive parent/s,
Adoption Services must take steps to contact the birth parent/s to ask if they wish
to consent to the release of information, except in circumstances where Adoption Services is aware
that the birth parent/s do not wish to give consent, or do not wish to be contacted for the purpose of obtaining consent.
Adoption Services may provide or may arrange for information, counselling and support to be provided
to assist you in relation to your application, or to the person whose consent to the identifying information is required. This may include
providing personal information about you to another party that may influence their decision.
If you apply for, or give consent for your adopted child to apply for, and then receive information about
the child’s birth parent/s, and the birth parent/s makes an application for identifying information, the birth
parent/s may be given the following information:
•
•
•
your name and your spouse’s name at the time of the adoption
the name of the child immediately after the adoption
copies of certain documents, including a copy of the adoption order.
With your written consent the birth parent/s may also be given your current name and address as provided on this form. You can
consent to the release of your current name and address using this form or you may want to consider giving your consent at a future
time.
If you are an adopted child please complete Part A of this form and ensure that your adoptive parent completes
Part B of this form.
If you are an adoptive parent applying for information about your child’s birth parents please complete Part C of this form.
Please attach additional pages if you wish to provide further information.
Please tick boxes where required and print clearly using BLOCK LETTERS.
Proof of identity
You are required to provide the original or a certified copy of two documents to prove your identity, for example, driver licence,
passport, birth certificate, pension card, credit card, Medicare card or student card. If you have produced the original of the two
documents for inspection and copying by a departmental officer you do not need to attach a certified copy of the proof of ide ntity
documents to this form. The full list of identification documents that may be accepted is available on the Department of Communities,
Child Safety and Disability Services website www.communities.qld.gov.au
An appropriate person to witness your signature must be present when you sign this form. The witness cannot be a relative. An
appropriate witness includes:
•
An officer of the Department of Communities, Child Safety and Disability Services
•
A lawyer or notary public
•
A Justice of the Peace or Commissioner for Declarations
•
A Police Officer
•
A medical practitioner
Information to assist you to locate a Justice of the Peace is available at: http://www.justice.qld.gov.au
Please return completed form:
by mail to:
Adoption Services
Department of Communities,
Safety and Disability Services
GPO Box 806
Brisbane QLD 4001
by courier or in person to:
Adoption Services
Department of Communities,
Child Safety and Disability Services
Level 1, 111 George Street
Brisbane QLD 4000
Assistance in completing this
form is available from:
Adoption Services
Telephone: 3224 7415 or Child
1800 647 983 (free call within
Queensland)
Post Adoption Support Queensland
Telephone: 1300 914 819
Form 11
Version 4
Page 1 of 7
Application for adoption information by an
adopted child or his or her adoptive parent/s
Adoption Act 2009 (sections 254 and 256)
Adoption Regulation 2009 (section 11)
Part A – To be completed by an adopted child who is applying for information
Current surname
Current given name/s
Your name at the time of your
adoption (if known and if different
from your current name)
Date of birth
Date of adoption (if known)
Residential address
Gender
Male
Female
Place of adoption
(if known)
Number and street address
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------State/Territory
Postal address
------------------------------------------Postcode---------------------------
as above
Number and street address
--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Suburb------------------------------------------------------------------------------------------State/Territory
Telephone numbers - please
indicate with an * which phone
number is your preferred contact
number
------------------------------------------Postcode------------------------
Home:
----------------------------------------------------------------------------------------------------Mobile:
----------------------------------------------------------------------------------------------------Work:
-------------------------------------------------------------------------------------------------
Email address
(if applicable)
Are you of Aboriginal or Torres
Strait Islander descent?
Yes, Aboriginal descent
Yes, Torres Strait Islander descent
Yes, Aboriginal and Torres
Strait Islander descent
Unknown
No
Full name of adoptive mother
Full name of adoptive father
Unknown
Surname:
----------------------------------------------------------------------------------------------------Given name/s:
----------------------------------------------------------------------------------------------------Surname:
----------------------------------------------------------------------------------------------------Given name/s:
-----------------------------------------------------------------------------------------------------
Form 11
Version 4
Page 2 of 7
Application for adoption information by an
adopted child or his or her adoptive parent/s
Adoption Act 2009 (sections 254 and 256)
Adoption Regulation 2009 (section 11)
Adopted child’s declaration (if applicable)
I,
hereby make application for pre-adoption
(full name of child, if applicable)
information and declare that all the information provided in this application is true and correct to the best of my
knowledge.
Signature of child (if applicable)
Date
/
/
Place (city/town)
Note: If is an offence under the Adoption Act 2009 for any person to knowingly provide false or misleading
information.
Part B – Adoptive parent/s consent to an application for information being made
by adopted child
An application for pre-adoption information can only be made by an adopted child with the consent of an
adoptive parent/s.
Please complete this section to indicate whether you give consent for your adopted child to make an application
for pre-adoption information:
Yes – I/We consent to my/our child
making an application for pre-adoption information.
(full name of child)
No – I/We do not consent to my/our child
making an application for pre-adoption information.
(full name of child)
OR
Part C – Release of information (completion of this section is optional)
Complete this section if you want to consent to your current name and address
being given to your child’s birth parents if they apply for information.
Although you are completing this form to give your consent to your son or daughter to apply for pre-adoption
information, you may wish to take the opportunity to complete this section to give your consent to your child’s
current name and address (as provided on this form) being given to a birth parent if the birth parent makes an
application for identifying information about your son or daughter.
If you give your consent for your child’s current name and address being released to a birth parent and
wish to later withdraw this consent, you will need to advise Adoption Services in writing.
Please indicate below whether you consent to you and your child’s current name and address information being
given to a birth parent at this time:
Yes – I/W e consent to my/our child’s current name and my/our child’s current address as provided on this
form being given to a birth parent/s if they make an application for adoption information
OR
No – I/We do not consent to my/our child’s current name and address as provided on this form being given to a
birth parent/s if they make an application for adoption information.
Form 11
Version 4
Page 3 of 7
Application for adoption information by an
adopted child or his or her adoptive parent/s
Adoption Act 2009 (sections 254 and 256)
Adoption Regulation 2009 (section 11)
OR
I/We would like to consider giving consent to my/our child’s current name and address as provided on this
form being given to a birth parent at the time an application for identifying information is made by the birth
parent. I/We want Adoption Services to contact me/us about this if a birth parent makes an
application for information in the future.
Adoptive Mother
Adoptive Father
Full name (if applicable)
Signature (if applicable)
Date
Place (City/town)
Part D - This section is to be completed by an adoptive parent/s applying for
pre-adoption information about their adopted child
Adoptive Mother
Adoptive Father
Preferred title (for example,
Mr, Mrs, Ms, Dr)
Current surname
Current given names
Previous names (If you have
changed your name by marriage
or deed poll please attach
certified copy of marriage or deed
certificate)
Date of birth
Place of birth
Residential address
Postal address
Form 11
Version 4
Number and street address
-------------------------------------------------------
Number and street address
------------------------------------------------------
-------------------------------------------------------
------------------------------------------------------
Suburb--------------------------------------------
Suburb--------------------------------------------
State/Territory ---------------------------------
State/Territory ---------------------------------
Postcode-----------------------------------------
Postcode----------------------------------------
as above
as above
Number and street address
-------------------------------------------------------
Number and street address
-------------------------------------------------------
-------------------------------------------------------
-------------------------------------------------------
Suburb---------------------------------------------
Suburb--------------------------------------------
State/Territory ----------------------------------
State/Territory ----------------------------------
Postcode------------------------------------------
Postcode-----------------------------------------Page 4 of 7
Application for adoption information by an
adopted child or his or her adoptive parent/s
Adoption Act 2009 (sections 254 and 256)
Adoption Regulation 2009 (section 11)
Adoptive Mother
Adoptive Father
Telephone numbers please indicate with an *
Home………………………………………….
Home…………………………………………..
which phone number is your
preferred contact number
Mobile………………………………………
Mobile……………………………………….
Work ………………………………………….
Work…………………………………………
Email address
Are you of Aboriginal or
Torres Strait Islander
descent?
Yes, Aboriginal
Yes, Aboriginal
Yes, Torres Strait Islander
Yes, Torres Strait Islander
Yes, Aboriginal and Torres Strait
Islander
Yes, Aboriginal and Torres Strait
Islander
No
No
Unknown
Unknown
Details of child who is adopted
Current surname
Current given name/s
Child’s name at time of
adoption (if known)
Date of birth
Gender
Male
Female
Date of adoption (if known)
Is the child deceased?
Place of birth
(if known)
ACR number
(if known)
Place of adoption
(if known)
No
Yes
If yes, please attach a certified copy of the death certificate to this form.
Child’s views (if applicable)
Is your child aware that you are applying for his or her pre-adoption information?
Yes
No
Not applicable
Is your child aware that Adoption Services will need to contact him or her to ask his or her views about your application
(having regard to your child’s circumstances and/or age and ability to understand)?
Yes
Form 11
Version 4
No
Not applicable
Page 5 of 7
Application for adoption information by an
adopted child or his or her adoptive parent/s
Adoption Act 2009 (sections 254 and 256)
Adoption Regulation 2009 (section 11)
Part E - Proof of identification and declaration
Identification documents
I/We have provided two original proof of identification documents and these documents have been sighted by a
departmental officer (please tick)
Yes
No
I/We have attached a certified copy of the two proof of identification documents.
Yes
No
A certified copy of the following two proof of ID documents has been provided:
Adoptive Mother (if applicable)
Identification Document 1
Identification Document 2
Adoptive Father (if applicable)
Identification Document 1
Identification Document 2
Child (if applicable)
Identification Document 1
Identification Document 2
Adoptive parent/s declaration
I,
and
(full name of adoptive mother, if applicable)
(full name of adoptive father, if applicable)
hereby make application for pre-adoption information and declare that all the information provided in this application
is true and correct to the best of my knowledge.
Adoptive Mother
Adoptive Father
Signature
Date
Place (city/town)
Note: If is an offence under the Adoption Act 2009 for any person to knowingly provide false or misleading
information
Form 11
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Page 6 of 7
Application for adoption information by an
adopted child or his or her adoptive parent/s
Adoption Act 2009 (sections 254 and 256)
Adoption Regulation 2009 (section 11)
Certificate of witness
Witness’ full name
Qualification
Departmental officer
Justice of the Peace
Lawyer
Commissioner of declarations
Police officer
Doctor
Registered number
(if known)
Phone Number:
Address
The applicant showed me two documents that provide proof of his or her identity.
This application form was signed by the applicant in my presence on
Date
/
/
at place
(insert State/Territory)
Witness’s signature
Privacy Notice
The Adoption Act 2009 authorises the Department of Communities, Child Safety and Disability Services to
collect the information on this form for the purposes of assessing your application for pre-adoption
information, and where applicable, the provision of the relevant identifying and non-identifying information.
The Department of Communities, Child Safety and Disability Services may provide some or all of this
information to the Registrar, Births, Deaths and Marriages and/or to a relevant tribunal or court or person as
authorised under the Act. All information obtained in the process of assessing your application for preadoption information, and where applicable, the provision of the relevant identifying and non-identifying
information will be managed in accordance with the Information Privacy Principles described in the
Information Privacy Act 2009.
Form 11
Version 4
Page 7 of 7