Contact Preference Register (CPR B)

Contact Preference Register (CPR) - Form B

Application Form B: Relatives looking to contact or share information with an adopted person

Section 1: About this form
Please read the CPR information leaflet carefully before you complete this form

We encourage you to give us as much information as possible. The more information we have to work with, the greater the chances are that we will help you make a match with relatives.

What is the Contact Preference Register (CPR)?

The main function of the Contact Preference Register is to enable contact between family members affected by adoption. The Register also serves as a way to lodge a contact preference, including a request for privacy. Applicants to the register can lodge an item (for example, a letter or photograph) for a specified person, which will be given to the specified person if they join or have previously joined the register.

About the words we use in this form

We have tried to use terms that would suit everyone involved in adoption. For ease of use, the terms ‘mother’ and ‘father’ refer to the ‘natural birth’ mother and ‘natural birth’ father. We use the term ‘applicants’ for people who register with the CPR.

Personal identification (ID)

You will need to include a copy of your personal identification with this form.

The types of personal identification we accept are:
- Passport
- Driving Licence (including provisional licence)
- Garda Age Card
Nominating a friend or family member to complete this form on your behalf

You can nominate a friend or family member to complete this form for you. You will find information on how to do this in our CPR information leaflet.

What happens after I send in my application form?

When we receive this application form, we will write to you to let you know. We will tell you that you are now being added to the Contact Preference Register (CPR).

If we find a possible match for you on the CPR, we will tell you what the next steps are. This will depend on the contact preferences you and the person you are matched with have chosen, and may include the following.
1. The sharing or requesting of information.
2. The opportunity of contacting the applicant with whom you are matched.
3. The opportunity to use the mediation service provided by the Adoption Authority.
4. Access to any specific items that may have been lodged.
For more information, please read our CPR information leaflet.

If you wish to know about how we use and store your personal data, please read our CPR privacy statement.

Section 2: Your current personal details
Section 2: Your current personal details

Please provide your email address, postal address or phone number, so we can contact you to confirm that we have received your application form.
Your full name*

First NameLast Name
Maiden name (if applicable):
Your date of birth (if unsure or not known, please provide the date you are most confident of)*

DayMonthYear
Date
Your email address*
example@example.com
Do you consent to us contacting you at this email address?*

YesNo
Your postal address*

Street Address

Street Address Line 2

CityCounty / State

Postal / Zip CodeCountry
Do you consent to us contacting you at this postal address?*

YesNo
Your phone number (landline or mobile)*
Do you consent to us contacting you at this phone number?*

YesNo
If you do not consent to us contacting you using any of the information above, please give alternative contact details here.
Have you nominated a friend or family member to complete this form on your behalf? If you answer yes to this question, please see our CPR information leaflet for steps on what to do.*

YesNo

Section 4: What level of contact do you want to have with this person?
Section 4: What level of contact do you want to have with this person?

You can choose more than one of these options. Please tick the boxes to show your preference
YES Contact options

I would like to contact the person named in Section 3I am willing to be contacted by the person named in Section 3I am looking for information about the person named in Section 3
NO contact options

I do not want contact with the person named in Section 3I do not want contact, but I am willing to share information about the person named in Section 3 if requested. Please provide details below.
Please provide details here
In keeping with the Adoption Authority’s legal obligation, where a request for records or information is received from a relevant person and a preference of ‘no contact’ has been registered by a parent on the CPR, the Adoption Authority will conduct an information session with the relevant person. This session may be done over a phone call or at a face-to-face meeting as requested. The Adoption Authority will inform the relevant person of their family member’s right to privacy and convey their preference to have ‘no contact’.

Please be aware that even if you choose a no-contact preference, you may, at a later date, be contacted by a member of staff from the Adoption Authority or the Child and Family Agency (Tusla) if necessary.
Sharing or looking for information

Please choose the relevant categories and use this space to share or request any medical or background information. If you need more space, please write on a separate page.
I would like to exchange medical information with the person named in Section 3

YesNo
If ‘Yes’, please give your medical information here
I would like to exchange background information with the person named in Section 3.

YesNo
If ‘Yes’, please give your background information here

Section 5: Other contact options
Section 5: Other contact options

Someone other than the specified person(s) you have named in Section 3 may join the register looking for you.
If someone other than the specified person(s) you have named in Section 3 joins the register looking for you or to share or seek information, would you like to be contacted by the AAI?*

Yes: I would like to be contactedNo: I am only interested in the person I have named in Section 3

Section 6: Lodging an item of interest
Section 6: Lodging an item of interest
If you wish to lodge an item(s) for the person named in Section 3, please choose the best description of the item(s) in question.

LetterPhotographOther
If choosing other, please give a brief description of the item in the space provided below.
You can upload letters and photograph files here.

Cancelof
If you would like to send original letters, photographs or momentos (present, family heirloom etc.) for the person named on your CPR application form, please package securely, include your name and contact details and send to the following address:

Information and Records Unit
Adoption Authority of Ireland
Shelbourne House
Shelbourne Road
Dublin 4
D04 H6F6

Section 7: Identification and signature
Section 7: Identification and signature
I, the Applicant, consent to my scanned written signature or my electronic signature or my typed signature being used by the Adoption Authority of Ireland to authorise my agreement to the information provided on this form.*

YesNo
By signing this form, I acknowledge that to the best of my knowledge, all information given by me is true and accurate. I also confirm that the personal identification provided by me is true and accurate.*

YesNo
What form of identification are you sending with this application?
Please choose which form of identification you are sending with this application? *
Old Id Question*
Upload identification*

Cancelof
By signing this form:
- I acknowledge that to the best of my knowledge, all information given by me is true and accurate.
- I consent to my scanned written signature or my electronic signature or my typed signature being used to authorise the processing and storing of my data on the Register.
- I understand that I may withdraw my consent at any point by advising the Adoption Authority I wish to be removed from the Register.
- I confirm that the personal identification provided by me is true and accurate.
Your signature or mark*

Clear
Date signed*

DayMonthYear
Date
Note: This is an extremely serious and sensitive matter for those involved. The Adoption Authority will report any person who misuses this form to An Garda Síochána.
Please verify that you are human*
Should be Empty:

Contact Preference Register (CPR) - Form B

Section 2: Your current personal details

Section 3: Details of the relative you would like to contact, share information with or express a contact preference for

Please indicate your status as an applicant

Person 1

Please give as much information as you can below. If you don’t have this information, just leave it blank.

Person 2

Please give as much information as you can below. If you don’t have this information, just leave it blank.

Person 3

Please give as much information as you can below. If you don’t have this information, just leave it blank.

Person 4

Please give as much information as you can below. If you don’t have this information, just leave it blank.

Section 4: What level of contact do you want to have with this person?

Sharing or looking for information

Section 5: Other contact options

Section 6: Lodging an item of interest

Section 7: Identification and signature