Release of Identifying Information Release of Identifying InformationI, have contacted Act of Love/Alternative Options and Services for Children (“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, home 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 to place my child for adoption, I hereby authorize Act of Love to release my name, home address, home telephone number and social security number to those who have provided medical services to me. I may also choose to provide such information to 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.By signing these documents electronically, I acknowledge that the electronic mark or symbol used to sign is representative of, functionally equivalent to, and shall be treated exactly the same as my handwritten signature. By making such a mark, I affirm that I do so with the intent to sign the forms or records so marked. I understand that by signing these documents electronically I will be bound by the terms of the documents, the same as if I had signed with my handwritten signature. Birth Mother Signature Date Birth Father Signature (If applicable) Date A Act of Love ·9561 South 700 East, Suite 101, Sandy, Utah 84070·(801) 572-1696·Fax (801) 572-9303 24-Hour Birth Parent Line 1-800-835-6360 ©Copyright A Act of Love 2010 Please leave this field empty.