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 Version 4 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
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