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HomeMy WebLinkAbout97-04292 - I > ! i : i , , i I '1 ~ ~ ..... ~ . . ~ ~ 4 / ~ , ~ J, i "'j J ~) t , \'00' ~I .1 ~, 1 j ., ". 4. The nalural father of the petitioner is Glenn Witkus whose lasl known address is unkno....ll. 5. Glenn Witkus has not been in contacl with Pelitioner since Pelilioner's birth, with Ihe exception of one isolated phone call some years ago. 6. Pelitioner has resided althe following locations during the pasl five years: A. I Eberly Drive. Shippensburg, Pennsylvania, 17257. B. 245 Easl Gunderson Apartment III, Carol Strcanl. llIinois, 60188. 7. Pelitioner wishes 10 adopllhe name Jennifer Kaval for Ihe follo....ing reasons: A. Petitioner has been using the name Kaval since her early childhood. (See Exhibit A). B. Pelilioner' s school records are in the name Kava!. C. Petilioner's social security number is registered for Ihe name Kava\. D. Petitioner's passport is in the name Kava\. E. Kaval is Petitioner's mother's married name. F. Petitioner's mother and husband, James Ka\'a/. have no objections 10 Petitioner's continued use of the name Kava/. (See Exhibil B). G. Petitioner's birth certificale is the only identification using the name Witkus in relation 10 Petilioner. It. Petitioner's natural father has made IlO effort to contact her outside of an isolated phone call nor has he assumed responsibility for Petitioner's upbrillJillJ. I. The ~ Knal rclkets what she feels to he her \rUe identity. IoHlll _IDICAL "ISTOIl' '_ J'" .~ f'U~nUl"."".f " ,nOfJ' (11,I(&11I.......... ..... .'llol. ~.;. "'IU';l'nli/l"U ....n..1I .,........I--Nl t." ".~C-.T~U. . . . . . :n".. \ -.' I;,.....,~ (..ClnAL I';"" '. :~ . : .'~ ~-......., :,":.~.fItt .u.~.....::~.:-.... ...'.' ~""",,&~ 4.",,_.~.'"'11 . '. ...'....,. . -:-. ....:~--...... , :p ..... . .....i-,.. .. .:...~~ . ..' .-'... . '. UJ.....~~. ,..0,::: :. .....-. - , ,; - . . 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ELMHURST CLINIC DATE OF REGISTRA TlON HIST.IIO.b7. :J.{g~ .(" 'to - 7.sa-! 260-0617 '~~:~....o,.:J / SHEET NO. 1 NAME J"nn He rfKava ~Wi tkus 1= EPHONE RIOS' ADDRESS 619 E. GUiide,tson Apt 1201 I;i&rol Streamtli-;-6\l llV ~K: SEX F AGE 9 DATE OF BIRTH It-lil-1lO RELIG.r NAME OF RESP. PARTY Debra Kava I RELATIONSHIP ADDRESS OF RESP. PARTY Same NAME OF OTHER PARENT OCCUPATION OF RESP, PARTY Unemp loyeo EMPLOYER BUSINESS ADDRESS REFERRED BY BIRTH HISTORY: HOSPITAL DELIVERY NEONATAL PROBLEMS WEIGHT HEIGHT COMPLICATIONS PERSONAL HEALTH HISTORY: . HOSPITALiZATiONS; MEDICAL ~--- SU~~CA~_ . . INFEcrIOvSDISEASES.J.:.M(!~ "'d"f-~qtY ALLERGIES- FOODS ~ AA: DRUGS ~ 4,'?O ..(- ACCIDENTS OR INJURIES ~" L (, '!A7( ~ CHRONIC MEDICAL "ROBLEMS 'V' OTHER L-OA- . GROWTH. DEVELOPMENT: SMILES _ _ COOS SITS ALCNE _ CRAWLS WALJ<S ALONE SINGLE WORDS BIB TRAINEO- DA Y NIGHT BEtiAVlOR PROBLeMS REACHES TURNS OVER STANDS ALONE _ PHRASES/SENTENCES ENURESIS LEARNING PROBLEMS · J..X.t.. -v.'"b,f,,;, FAMILY HISTORY: ~ J L.'/ ;1 PARENTS: FiTHER :;.,J.G~'k.~ ~L~-----:! ~_ MOTHER --ru~ SIBLiNGS ~~~ -' '1A: , -....---- -' --- - I.: :"-"'I ;p..---------- FAMILY Ht~l~'lr:Y OF,AL;.,E.RGY""':'_ -.... .-.. -. DIABETES"'/:' . CANCER . ~ CONGo ANO/l4ALY -'" .~--- .;e- HYPEI\TENSlO/14 HEART DISEASE __ "-in..fL- I'IEREOlTY :>>SE.~SE _.'_ __OTHER . ;:) '1 US . 6'8/ IMMUNIZATION RECOllDI OT" TOl"V Tl'Iv_ 0taI1"Ilflo Of c.CII\__' ra_us TT r_ ro.OId TU..RCUl.IN l ...- 4!'1. 7 -/ ! 5 '" .; ..; ..j.; . - .",,7 'l"::1o "'IotR !.J.;'" )0.;: MEASLES ... ., 'I. >' ;' I) l\\JIJELLA II .... y..;; .. ~ \ .. ~ . \"'- ... '" .,f' ,. .. ( ! -: oj,:) UUUPS IJ Ji. 'I: .; :t is'