Parent's Worksheet for Child's Birth Certificate | Guadalupe Regional Medical Center

Parent’s Worksheet for Child’s Birth Certificate

The information you provide on this worksheet is used to create your child's birth certificate. The birth certificate is a legal document used to prove your child's age, citizenship and parentage. Your child will use the birth certificate throughout his/her life. The State of Texas safeguards against the unauthorized release of identifying information from birth certificates to protect the confidentiality of parents and their child. Please FILL IN your responses carefully and accurately as errors are difficult and expensive to correct.

Date of Birth

Parent’s Worksheet for Child’s Birth Certificate

CHILD'S PLACE OF BIRTH

CHILD'S INFORMATION

MOTHER'S CURRENT LEGAL NAME

CHILD'S LEGAL NAME

MOTHER'S RESIDENCE ADDRESS

MOTHER'S MAILING ADDRESS (if same as residence address, LEAVE THIS SECTION BLANK)

MOTHER'S INFORMATION

MOTHER'S HEALTH INFORMATION

How many cigarettes did you smoke before and during pregnancy?

MOTHER'S MARITAL STATUS (Please read carefully)

ACKNOWLEDGEMENT OF PATERNITY

MOTHER'S NAME PRIOR TO FIRST MARRIAGE

FATHER'S INFORMATION

PRESUMED FATHER INFORMATION (Complete ONLY if applicable)

MOTHER'S MEDICAID INFORMATION (Complete ONLY if applicable)

IMMTRAC REGISTRY