Membership Application Form

Adoption Crossroads members living in New York City Metropolitan Area
or those whose birth was in New York City,
receive search help directly from our New York Office.

All others should click on our link (Search Support Sites)
to over 475 organizations for their assistance.

 You do NOT have to renew membership to maintain the entry)

Please do NOT rely on any registry for a reunion.

To become a member, fill out the information below.
Your membership will be effective immediately
and your search information will be emailed immediately. Good Luck in your search!

If you have a financial hardship, we will negotiate a fee with you.

Personal Information

If you are paying by Credit Card, the address you give
must be the address at which you receive your Credit Card Bill.
 
Your Name Mr. Mrs. Ms   First:   Last:
Street 1:   Street 2 :
City:   State/Prov.:    Zip: :
Country.:  Home Tel.: Bus. Tel.:
 E-mail:  (Req'd)     Confirm E-mail:  (Req'd)
Adoptee 1st parent Adopt. Par Other Soc Sec #

Biographical Information

 
Adoptee's Birthdate:enter birthdate as MM/DD/YY for example May 3, 67 would be 05/03/67
Adoptee's Name at Birth    First:  Last:
 Hospital: City of Birth: 
 State/Prov.:  Country
 Agency:   City:   State/Prov.: 
First mother's Name at time of adoptees birth
 First:  Last:    Maiden Name:
First father's Name at time of adoptees birth
 First:   Last: 

How did you hear about us?: 

Additional Info: - max 2,000 chars, aprox 200 words

Payment formation

 

 
 

One year membership in Adoption Crossroads $100 USD (For Adoptees Born in New York City)
One year membership in Adoption Crossroads $75 USD (For Adoptees Living in NYCy but born elsewhere)
One year membership in Adoption Crossroads $50 USD (For Parents Living in New York City)
Lifetime membership in Adoption Crossroads $500 USD

TOTAL Amount of payment:

Payment By:

Name on Card:

Card No.Card Expires

Security Code What is the security code?
If you are not paying by credit card, enter 00 in the Security Code Box above.

You may also make your payment by filling out this form and faxing it to:
845-267-2736, or you may Call 845-268-0283 and leave your credit card info;
on our answering machine, or you may send the payment via US Mail.

If paying by check, make the check out to Adoption Healing and mail it to

Adoption Healing
74 Lakewood Drive
Congers, NY 10920

If paying by Credit Card, please include the following info:
€Card Number, Name on Card, the Expiration Date (Month and Year)
and the credit card Security Code.

Please press the SUBMIT button below

To get more information or to order services by phone: call 845-268-0283 or send E-mail to us at joesoll@adoptionhealing.com


Last Updated on August 26, 2006 by Joe Soll 

© Copyright 2006 Adoption Crossroads, all rights reserved, logo's and graphics appearing on these pages are trademarks of Adoption Crossroads and may not be used or reproduced without permission. CERA is a New York State d.b.a. of Adoption Crossroads.