BRI _____________ CID _____________
If you have any questions, please contact: ServiceOntario Toll-free: 1 800 461-2156 or Toronto: 416 325-8305
Important: Please read through the instructions thoroughly before completing this form. Please print clearly in blue or black ink.
Mr. Mrs. Ms. Miss. Current Legal Surname (Last Name) First Name Middle Name(s) Maiden Name or Other Surname(s) (if applicable)
Male Female
Date of Birth (dd/mm/yyyy)
Street No. Street Name Apt. No. Buzzer No. PO Box City/Town Province/State Country Postal/Zip Code
Enter area code Enter telephone number Ext.
Yes No
Update the list of birth relatives with whom I wish to be matched. (Please complete PART B of the form) Update my contact information. (Please complete PART C of the form) Update my current legal name due to a legal name change. (Please complete PART D of the form)
I have previously applied to be named on the Adoption Disclosure Register and I wish to withdraw my name from the Register.(Please complete PART E of the form.)
Please indicate the changes you wish to make to the list of birth relative(s) with whom you wish to be matched. (Please check all the boxes that apply to you) This section applies to adopted persons only.
Add Remove
Important: The information you provide in this section will replace your contact information previously entered on the Adoption Disclosure Register. When updating your contact information, please ensure that you check all methods of contact that you wish to be entered on the Register and fill out the applicable sections. In the event that a register match is confirmed, the adopted person, birth relative, birth parent, birth sibling or birth grandparent will receive only the contact information you provide in the section below.
Please indicate how you wish to be contacted by the adopted person, birth relative, birth parent, birth sibling or birth grandparent in the event that a register match is confirmed by checking the boxes below and filling out those sections that apply to you. (You may check more than one box)
Enter area code Enter fax number
E-mail Address
Mr. Mrs. Ms. Miss.
Current Legal Surname (Last Name) First Name Middle Name(s)
Date of Legal Name Change (dd/mm/yyyy)
Previous Legal Surname (Last Name) First Name Middle Name(s)
I hereby request that my name be removed from the Adoption Disclosure Register under section 9 of O.Reg. 464/07 made under the Child and Family Services Act.
(Signature of Applicant)
(Date of Signature)
I hereby certify that the information I have provided on this application form is true and correct to the best of my knowledge and belief.
Mail your completed application to: Custodian of Adoption Information P.O. Box 654 77 Wellesley St. West Toronto ON M7A 1N3
The information provided on this form is collected and will be used to update your information or remove your name from the Adoption Disclosure Register under section 9 of O.Reg. 464/07 made under the Child and Family Services Act. If you have any questions about the collection of information please contact: Director, ServiceOntario Call Centre, Contact Centre Service Branch, 5775 Yonge St., Toronto ON M3M 3E6 or call 1 800 461-2156 / 416 325-8305.
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