Parent'S Custodian'S Consent To Adoption
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1
2ONTARIO
Court File Number
(Name of Court)
Form 34F: Parent’s or
at
Custodian’s Consent
Court office address
to Adoption
1. My name is
(full legal name)
I was born on
and I live
(date of birth)
at
(address)
2.
The child in this case is:
(Give child’s full legal name, date of birth, sex and birth registration number, if available.)
Full legal name
Date of birth
Sex
Birth registration number
3.
I am a parent of the child within the meaning of Part VII of the Child and Family Services Act because I am
(Check appropriate paragraph below.)
the child’s mother.
an individual who, during the 12 months before the child
was placed for adoption, has acknowledged parentage of
the child’s father.
the child and has provided for the child’s support.
the person presumed to be the child’s father under
an individual who is required to provide for the child or
section 8 of the Children’s Law Reform Act.
who has custody of or access to the child under a written
agreement or a court order.
an individual having lawful custody of the child.
an individual who has acknowledged parentage of the
an individual who, during the 12 months before the
child under section 12 of the Children’s Law Reform Act.
child was placed for adoption, has demonstrated a
settled intention to treat the child as a member of his/
her family.
4.
I consent to the adoption of this child.
5.
I understand the nature and effect of this consent. I understand that I may withdraw this consent as follows:
• If the child is placed for adoption by a children's aid society, by ensuring that the children's aid society located
at
(address)
receives my written notice of withdrawal within 21 days after my consent was given.
• If the child is placed for adoption by a licensee, by ensuring that the licensee located at
(address)
receives my written notice of withdrawal within 21 days after my consent was given.
• If a relative of the child or the spouse of a parent proposes to apply to adopt the child, by ensuring that the proposed
applicant receives my written notice of withdrawal within 21 days after my consent was given.
6.
I understand that, after the 21 days have passed, I am not allowed to withdraw this consent unless I first get the court’s
permission, and then only if my child has not yet been placed for adoption and if I can show that it is in the child’s best
interests that this consent be withdrawn.
7.
I understand the nature of an adoption order and that, if an adoption order is made, I will no longer be a legal parent to the
child.
8.
I understand that once the child turns eighteen years old, he/she can apply for a copy of his/her original birth registration, if
any, and a copy of his/her adoption order. I understand that my full legal name may be included on such copies.
9.
I understand that once the child turns nineteen years old, his/her birth parent(s) may apply for information from his/her
original birth registration, if any, any substituted birth registration, and his/her adoption order. This information would include
the child’s full legal name after adoption.
10. I understand my right to ask and to be told whether an adoption order has been made for the child.
FLR-34F-E (2009/04)
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