Adoption Consent Form Template

I, [Full Name], make this Adoption Consent Form on [Date].

1. Person Giving Consent

Full Name: [Full Name]
Address: [Address]
City, State, ZIP Code: [City, State, ZIP Code]
Phone Number: [Phone Number]
Email Address: [Email Address]
Relationship to Child: [Mother / Father / Legal Guardian / Other]

2. Child Information

Child’s Full Name: [Full Name]
Date of Birth: [Date of Birth]
Place of Birth: [City, State, Country]
Current Address: [Address, if applicable]

3. Adoptive Parent or Parents

I consent to the adoption of the above-named child by:

Adoptive Parent 1: [Full Name]
Address: [Address]

Adoptive Parent 2: [Full Name, if applicable]
Address: [Address]

4. Consent Statement

I voluntarily and knowingly consent to the adoption of the child identified in this form.

I understand that by giving this consent, I may be giving up parental rights and responsibilities to the extent provided by applicable law and court order.

5. Acknowledgment of Understanding

I confirm that:

☐ I am signing this form voluntarily
☐ I understand the purpose and effect of this consent
☐ I have had the opportunity to ask questions before signing
☐ I understand that court approval may still be required
☐ I understand that revocation may be limited or controlled by law

6. Additional Statements

Additional information or required statements, if any:

[Insert agency language, state-specific wording, or other required statement]

7. Witness or Agency Information

Witness / Agency Representative Name: [Full Name]
Title or Role: [Witness / Social Worker / Agency Representative / Other]
Address: [Address]
Phone Number: [Phone Number]

8. Signature

Signature of Person Giving Consent: __________________________
Name: [Full Name]
Date: [Date]

9. Witness Signature

Witness Signature: __________________________
Name: [Full Name]
Date: [Date]

10. Notary Acknowledgment

State of [State]
County of [County]

On this [Day] of [Month], [Year], before me, the undersigned notary public, personally appeared [Name of Signer], known to me or satisfactorily proven to be the person whose name is subscribed to this instrument, and acknowledged that they executed the same for the purposes stated herein.

Notary Public Signature: __________________________
Name: [Notary Name]
My Commission Expires: [Date]