Consent To Appointment Of Permanent Custodian Form printable pdf download

3/10/07

184

IN THE DISTRICT COURT OF ____________ COUNTY, KANSAS

IN THE INTEREST OF:

______________________________

Case No. ______________

DOB xx /xx /____ A G male G female

CONSENT TO APPOINTMENT OF PERMANENT CUSTODIAN

Pursuant to K.S.A. 38-2268

NOTICE TO PARENT: THIS IS AN IMPORTANT LEGAL DOCUMENT. WHEN YOU

SIGN THIS RELINQUISHMENT, A PERMANENT CUSTODIAN WILL BE APPOINTED

FOR YOUR CHILD. THE PERMANENT CUSTODIAN SHALL EXERCISE ALL OF THE

RIGHTS AND RESPONSIBILITIES OF A PARENT, EXCEPT CONSENT TO ADOPTION

OR AS LIMITED BY THE COURT. YOU ARE STILL RESPONSIBLE FOR PAYING

CHILD SUPPORT.

_________________________

My name is __________________ and I am the G mother G father of the child named

above and I state to the Court:

My child, named above, was born on _____________________ in the

__________________ Hospital in the City of ________________, State of

_________________.

I presently reside at

___________________________________________________________

I am _____ years of age and was born on ______________________.

I understand that my parental rights are not being terminated and I can be ordered to pay

child support and medical support for my child.

I understand that to exercise any rights I still have I must keep the court up to date about

how to contact me, with my current address and telephone number.

I understand that if my child is ever placed for adoption, the court will try to let me know

by using the information I have given them, and if my address and telephone number are

not up to date I might not know if my child is placed for adoption.

I understand that if I want information about my child’s health or education I will have to

keep the court up to date about how to contact me, because the information will be sent to

the latest address the court has.

I understand that I may be able to have some contact with my child, but only if the

permanent custodian decides it is in the child’s best interests and if the court allows the

contact.

I understand that unless the court orders differently, the permanent custodian has the right

to make the following decisions about my child: the amount and type of contact I have with

my child; consent to my child’s marriage; consent to medical treatment for my child;

consent to mental health treatment for my child; consent to placement of my child in a

psychiatric hospital or an institution for the developmentally disabled; consent to

behavioral and medical experiments; consent to sterilization and consent to withholding

life-prolonging medical treatment.

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Consent To Appointment Of Permanent Custodian Form

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