Nevada Triad Registration

This is: A new submission An updated submission

I am a(n): Adoptee Birthmother Birthfather
Birthsibling Adoptive Parent Other (please specify)

First name:

Last name:

Your email address will only be used to contact you in case a match is found and to send you a monthly reminder to update your submission if there are any changes to your information. Please keep your email address current. Your phone number is optional, but also recommended for us to contact you in case a match is found. It will only be used for that purpose.

Email:

Area Code: Phone Number:

Address:

City:

State:

Zip Code:

INFORMATION ABOUT THE ADOPTEE

Sex of Adoptee: Female Male

Name at Birth (if known):

Amended name (if known):

Please do not guess or approximate the adoptee's birthdate. This date is very important when looking for a match. If you are uncertain about the month, day or year, please choose "Uncertain" from the drop-down menu.

Birthdate of Adoptee:

City of Birth:

State of Birth:

Hospital:

Delivery Physician:

Adoption Agency:

Place of Relinquishment:

County Where Adoption Finalized:

INFORMATION ABOUT THE BIRTH MOTHER

Name at Time of Adoptee's Birth:

Current Name:

Birth Mother's Date of Birth or Age Time of Adoptee's Birth/Placement:

Birth Mother's or her family's Location of Residence at Time of Adoptee's Birth:

Maternity Home:

INFORMATION ABOUT THE BIRTH FATHER

Name of Birth Father:

Birth Father's Date of Birth or Age at Time of Adoptee's Birth/Placement:

Birth Father's or his family's Location of Residence at Time of Placement:

In this area you may add 5 or 6 key words/phases that may help in making a match (up to 150 characters.) Please do not repeat information already noted in the form (such as birthplace or names). This area is also not for personal messages (such as "We love and miss you.")

Please review your information and click the submit button to send it to Nevada Triad.

**Please note that new and updated submissions are processed weekly. Therefore, it may take up to one week for your submission to show in the registry. If you have found a match on your own or through another registry, please let us know so we can update the registry showing your entry as "Reunited". You will be contacted by email once a month as a reminder to make any changes to your information. Thank-you.