RIGHTS I AM GIVING UP AND THAT AN ORDER TERMINATING MY PARENTAL RIGHTS, WHEN
ENTERED BY THE COURT, IS A PERMANENT TERMINATION OF ALL OF MY PARENTAL
RIGHTS.
________________________
Time
________________________
_____________________________________________
Date
Parent Signature
____________________________________________________________________________________
Address
City
State
Zip
The parent signing this out-of-court consent is an unemancipated minor. I am the parent/guardian/
guardian ad litem of the minor parent, and I consent to the minor parent signing this out-of-court consent
to adoption.
________________________
_____________________________________________
Date
Parent/Guardian of Unemancipated Minor
____________________________________________________________________________________
Address
City
State
Zip
Signed in the presence of and witnessed by:
___________________________________________________________________________________
Attorney Signature
Date
___________________________________________________________________________________
Attorney Name
Bar Number
___________________________________________________________________________________
Child Placing Agency Caseworker Signature
Date
___________________________________________________________________________________
Child Placing Agency Caseworker Name
___________________________________________________________________________________
Child Placing Agency Name
Prepared by:
Herbert A. Brail and Stephanie L. Benedict, Attorneys at Law, 930 Mason, Dearborn, MI 48124
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