Consent To Place A Child For Adoption And Waiver Of Notice And Appearance Page 2
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3CONSENT TO PLACE A CHILD FOR ADOPTION and WAIVER OF NOTICE AND APPEARANCE
I, _________________________________________, born on ______________________, am the _____________________of
(Parent’s Full Name)
(Date of Birth)
(Relationship)
__________________________________________, born on______________________, in________________________.
(Child’s Full Name)
(Date of Birth)
(City, State, Country)
I am signing this consent to give my permission for___________________________________________________ to adopt the above
named child.
(Full Name of Prospective Adoptive Parent/s)
I understand that my parental rights will be terminated based upon the grounds of this consent to adoption. (A.R.S. § 8-533(B)(7).
I further understand that I no longer will have any legal rights, privileges, duties and obligations, including the right to custody and
the right to visit the child. The only exceptions are that my obligations to pay support and the child’s right to inheritance will
continue until the child’s adoption is final.
At the time the child’s adoption is final, the adoptive family will have the same legal rights, privileges, duties and obligations as if the
child had been born to them, and all my rights and obligations, including my obligations to pay support and the child’s right to
inheritance, will be completely ended. (A.R.S. § 8-117)
I am signing this consent freely and voluntarily and not as a result of any fraud, duress or undue influence (force or trickery). I
understand that once this consent is signed, I cannot revoke (cancel or withdraw) it unless it was obtained by fraud, duress or undue
influence. (A.R.S. § 8-106)
I have been advised of the provisions of A.R.S. § 8-106 (E) and
□ give my permission □ withhold my permission for this child to
obtain identifying information about me and his/herself upon reaching age 18. I understand that my decision to grant or withhold
this permission may be changed at any time by filing a notarized statement with the court and this agency.
I voluntarily give up my rights to all notices and appearances to any and all hearings or proceedings in connection with the
dependency, severance, and adoption of the above-named child.
I understand that this means I will NOT be notified on any such hearings or proceedings, and that my attendance will NOT be
required OR expected. I understand that these hearings and proceedings will take place without my presence, and that the result of
the hearings and proceedings most likely will be that ALL my rights to the child, including the right to custody, care, control and
visitation will be completely ended.
Dated this __________ day of _______________________, 20____, at _____________ ___.m.
(DAY)
(MONTH)
(TIME)
Parent’s Signature: __________________________________________
Parent’s Address: _________________________________________________________________________
Street Address
City
State
Zip
Signed before me on _______________________, 20___ at __________
(DATE)
(TIME)
My commission expires:
____________________
Notary Public: ______________________________________________________
Street Address: ______________________________________________________
City, State, ZIP: _____________________________________________________
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