Adoptee – A1 Membership Form

Contact Adoption Jigsaw

2A Curtin Avenue, Cottesloe 6011

Post Box 819
Cottesloe 6911

Phone: 08 9384 0222
Fax: 08 9384 7192
Email address:
jigsaw@jigsaw.org.au
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Adoptee – A1 Membership Form

In order to assist you, you must first obtain your documents from the relevant state Government Adoption Dept. This usually takes many months so we advise you to do this prior to joining Jigsaw. We encourage Perth people to attend our discussion groups. You are welcome to contact us to discuss any matter.

Note that this application requires your signature, you can post, fax or scan and email it to us.

JIGSAW FEES – $250 incl. GST

Jigsaw is a membership based not-for-profit organisation. To reduce administration costs we charge one fee regardless of the search and mediation work involved.

Membership entitles you to:

Full Voting Rights
Newsletter – Jigsaw Pieces published bi-monthly.
Use of Jigsaw library
Registration on our Contact Register
Use of Jigsaw facilities for search

Please contact us to discuss any special problems with fees.

It is not possible to advise you regularly about the progress of your search or mediation, however you are welcome to contact us for an up date.

Create Downloadable Membership Application

Please enter details into the following form fields. Once complete click the Submit button to download a PDF version of the membership form.

Print this form and then fill in the outstanding details such as payment details and signatures.

Once complete please send the signed, completed form to Jigsaw by either email, fax or post.

Current Details

Title
Gender
Surname
First Name
Second Name
Address
Postcode
State
Country
Can we write to this address?
Phone (H)
Phone (W)
Mobile
Email
Can we leave a message at these phone numbers?
Perth Clients Only - Can we send you a text or email reminder of Jigsaw event/support meetings?
Do you want to receive newsletters?
Any special instructions in regards to contacting you?
Have you had any contact with any member of your birth family?
If Yes above, Who?
If Yes above, When?
For whom are you searching?

BIRTH DETAILS - Names at the Time of YOUR Birth

(Fill in ONLY details you know for sure, otherwise leave blank)

Surname
First Name
Second Name
Date of Birth
Hospital
City
State

Adoptive Family

Mother's Surname
Mother's First Name
Mother's Second Name
Father's Surname
Father's First Name
Father's Second Name

BIRTH MOTHER

(Information at the time of YOUR birth)

Surname
First Name
Second Name
Address
State
Post Code
Date of Birth
Age when you were born?
Marital Status
Occupation
Her place of birth
Nationality
Current surname if know
Any other signification information

BIRTH FATHER

(Information at the time of YOUR birth)

Surname
First Name
Second Name
Address
State
Post Code
Date of Birth
Age when you were born?
Marital Status
Occupation
His place of birth
Nationality
Does he know of pregnancy/birth?
Any other signification information

Adoption Documents

When sending through the membership application form please also attach any copies of your documents. Please attach whatever documents you have. If you are uncertain please contact us.

Your original birth certificate with your birth mothers name?
Court documents?
Information about your adoption?

Searching

Have you conducted a search yourself?
If yes, please provide copies of any certificates you obtained and summarise the search:

IMPORTANT INFO

Please provide details of a close contact NOT living at your address so that we can contact in the event you change your address and do not notify us:

Name
Address
Post Code
Phone (H)
Phone (W)
Mobile
Email
Relationship to you?
Can we identify ourselves as Jigsaw?

Contact Adoption Jigsaw

Make a Gold Coin Donation

Postcard Project

"Adoption Secrets"

Adoption Books

Join Adoption Jigsaw

Reconnections