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Birth Record Files Application

2. SKOKIE HEALTH DEPARTMENT APPLICATION FOR SEARCH OF BIRTH RECORD FILES

3. 

5. Child's Full Name:

   *Child must have been born in Skokie.

6. Please Check:

   1. M
   2. F

8. Date of Birth:

9. Number of Copies Requested:

11. Father's Full Name:

13. Mother's Full Maiden Name:

15. FEE: $10.00 for the first copy and $5.00 for each additional copy ordered at the same time. You may pay by CASH, CHECK or CREDIT CARD (Master Card, Visa, or Discover). If requesting certificates by mail you must include a copy of a valid photo ID and S/H rates may apply, call 847-933-8252 for S/H rates.

17. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
19. Electronic Signature*

21. Printed Name:

23. Relationship to Child:

25. Address:

27. City/State:

28. Zip Code:

30. Daytime Phone Number:

32. Please upload a copy of your government issued ID*

    Applications are not complete until a copy of your government issued ID is received.

34. Please call the Skokie Health Department to verbally submit payment for your application.
    847-933-8252

    847-933-8252

Leave This Blank:


36. 1. Receive an email copy of this form.
37. Email address

    This field is not part of the form submission.

38. Submit Submit and Print

* indicates a required field