In the petition relating to the adoption of

(Insert the full name of the child as it is given in the birth certificate)

to which petition the court has assigned the serial number

I, (name and address)

confirm that I am the mother/father/guardian of the child. I fully understand that the effect of the adoption order for which application has been made will be to deprive me permanently of all parental rights or responsibilities which I have at present over the child. I freely agree generally and unconditionally to the making of an adoption order in relation to the child.

I have signed this agreement at (place of signing)

on the day of Nineteen hundred and.

This agreement was signed in the presence of:—

(Signature of reporting officer)

Full name of Reporting Officer

Address