Consent To Appointment Of Permanent Custodian Form (Page 2 of 2) in pdf

Consent To Appointment Of Permanent Custodian Form Page 2

3/10/07

10. I understand this consent is final.

11. I understand the permanent custodian will have full authority and all the rights of a birth

parent or legal guardian over the child, except the power to place the child for adoption and

give consent to adoption, and as otherwise limited by the court.

12. I consent to the appointment of a permanent custodian by the court.

13. I have read and understand the above and I am signing it as my free and voluntary act.

Dated this _______ day of _________________, _______, in the City of ______________,

County of ______________, State of Kansas at _______ G a.m. G p.m.

__________________________

CERTIFICATE OF ATTORNEY

I have fully explained to the parent named above that by signing this consent the custodian

will exercise all parental rights to the child, except the right to consent to adoption, and s/he

confirmed that intention and desire.

Date: _______________

___________________________

S.Ct.#_________________

ACKNOWLEDGMENT BEFORE JUDGE OF DISTRICT COURT

STATE OF KANSAS,

)

) ss:

COUNTY OF _______,

)

I, __________________________, am a Judge of the District Court, ______________

Judicial District, and I hereby certify that _____________________________, known to me to

be the same person whose name is subscribed to the foregoing consent, appeared before me this

day in person and acknowledged the consent and it was a free and voluntary act.

I have fully explained that by signing such consent the custodian will exercise all of the

parental rights to such child as explained in the consent form and s/he stated that such is his/her

intention and desire.

Date: _____________________

_________________________

Judge of the District Court

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Consent To Appointment Of Permanent Custodian Form Page 2