"" 1 Name Last Name Act of Love Release of Identifying Information Ino-icon have contacted Act of Love for the purpose of possibly placing my child for adoption. Should I choose not to place my child for adoption, I understand that it may become necessary for Act of Love to provide my name, home address, telephone number and social security number to medical providers so that arrangements can be made for my medical bills to be paid. As such, if I choose not io place my child for adoption, I hereby authorize Act of Love to release my name, home address, telephone number, and social security number to those who have provided medical services to me. I may also choose to provide such information io the medical providers on my own. I release and hold harmless Act of Love from any claims, causes of action, injuries. damages, or losses arising from the release of such information to my medical providers. Birth Mother Signatureno-icon Dateof signaturedate_range Witness Signatureno-icon Dateof signaturedate_range NEXT Previous Next
