A. I, _______________________________, am the mother/father of the minor child subject to this consent who is:
[Child’s Current Name, Gender, Birth date/time, Birthplace]
B. I relinquish all rights to and custody of this minor child to ____________________________, the adoption entity, with full knowledge of the legal effect of the adoption and I consent to the termination of my parental rights to the child as well as the child’s adoption.
C. I understand my legal rights as a parent. I have read and understand the following Consent Disclosure, and I understand that I do not have to sign this consent and release of my parental rights. I acknowledge that this consent is being given knowingly, freely, and voluntarily. I further acknowledge that my consent is not given under fraud or duress. I understand that the right to revoke this consent is limited to very narrow circumstances that may not apply to me. I understand that, in signing this consent, I am permanently and forever giving up all my parental rights to and interest in this minor child. I voluntarily, permanently relinquish all my parental rights to this minor child. I understand I may have the right to notice of any hearings pertaining to the termination of my parental rights and/or the adoption of the child. I hereby waive and relinquish the right to such notice.
This consent is required by Florida Statute to include (in at least 12-point boldfaced type) all of the following information. The information in this disclosure may not apply to your particular situation.
YOU HAVE THE RIGHT TO SELECT AT LEAST ONE PERSON WHO DOES NOT HAVE AN EMPLOYMENT, PROFESSIONAL, OR PERSONAL RELATIONSHIP WITH THE ADOPTION ENTITY OR THE PROSPECTIVE ADOPTIVE PARENTS TO BE PRESENT WHEN THIS AFFIDAVIT IS EXECUTED AND TO SIGN IT AS A WITNESS. YOU MUST ACKNOWLEDGE ON THIS FORM THAT YOU WERE NOTIFIED OF THIS RIGHT AND YOU MUST INDICATE THE WITNESS OR WITNESSES YOU SELECTED, IF ANY. LIST HERE THE NAME OF THE PERSON, IF ANY, THAT YOU HAVE SELECTED TO WITNESS YOUR SIGNATURE (IF YOU HAVE CHOSEN NOT TO SELECT A WITNESS, WRITE “NOT APPLICABLE”): ___________________________________________________.
YOU DO NOT HAVE TO SIGN THIS CONSENT FORM. YOU MAY DO ANY OF THE FOLLOWING INSTEAD OF SIGNING THIS CONSENT OR BEFORE SIGNING THIS CONSENT:
1. CONSULT WITH AN ATTORNEY;
2. HOLD, CARE FOR, AND FEED THE CHILD UNLESS OTHERWISE LEGALLY PROHIBITED;
3. PLACE THE CHILD IN FOSTER CARE OR WITH ANY FRIEND OR FAMILY MEMBER YOU CHOOSE WHO IS WILLING TO CARE FOR THE CHILD;
4. TAKE THE CHILD HOME UNLESS OTHERWISE LEGALLY PROHIBITED; AND
5. FIND OUT ABOUT THE COMMUNITY RESOURCES THAT ARE AVAILABLE TO YOU IF YOU DO NOT GO THROUGH WITH THE ADOPTION.
IF YOU DO SIGN THIS CONSENT, YOU ARE GIVING UP ALL RIGHTS TO YOUR CHILD. YOUR CONSENT IS VALID, BINDING, AND IRREVOCABLE EXCEPT UNDER SPECIFIC LEGAL CIRCUMSTANCES. WHEN THE MINOR TO BE ADOPTED IS OLDER THAN SIX MONTHS OF AGE AT THE TIME OF EXECUTION OF THE CONSENT, THE CONSENT TO THE ADOPTION IS VALID UPON EXECUTION OF THE CONSENT, HOWEVER, IT IS SUBJECT TO A THREE-DAY REVOCATION PERIOD OR MAY BE REVOKED AT ANY TIME PRIOR TO THE PLACEMENT OF THE MINOR WITH THE PROSPECTIVE ADOPTIVE PARENTS, WHICHEVER IS LATER. IF A CONSENT HAS BEEN EXECUTED, THIS SUBSECTION MAY NOT BE CONSTRUED TO PROVDIE A BIRTH PARENT WITH MORE THAN THREE DAYS TO REVOKE THE CONSENT ONCE THE CHILD HAS BEEN PLACED WITH THE PROPSECTIVE ADOPTIVE PARENTS.
IF YOU ARE GIVING UP YOUR RIGHTS TO A NEWBORN CHILD WHO IS TO BE IMMEDIATELY PLACED FOR ADOPTION UPON THE CHILD’S RELEASE FROM A LICENSED HOSPITAL OR BIRTH CENTER FOLLOWING BIRTH, A WAITING PERIOD WILL BE IMPOSED UPON THE BIRTH MOTHER BEFORE SHE MAY SIGN THE CONSENT FOR ADOPTION. A BIRTH MOTHER MUST WAIT 48 HOURS FROM THE TIME OF BIRTH, OR UNTIL THE DAY THE BIRTH MOTHER HAS BEEN NOTIFIED IN WRITING, EITHER ON HER PATIENT CHART OR IN RELEASE PAPERS, THAT SHE IS FIT TO BE RELEASED FROM A LICENSED HOSPITAL OR BIRTH CENTER, WHICHEVER IS SOONER, BEFORE THE CONSENT FOR ADOPTION MAY BE EXECUTED. A BIOLOGICAL FATHER MAY EXECUTE A CONSENT AT ANY TIME AFTER THE BIRTH OF THE CHILD. ONCE YOU HAVE SIGNED THE CONSENT, IT IS VALID, BINDING, AND IRREVOCABLE AND CANNOT BE WITHDRAWN UNLESS A COURT FINDS THAT IT WAS OBTAINED BY FRAUD OR DURESS.
IF YOU BELIEVE THAT YOUR CONSENT WAS OBTAINED BY FRAUD OR DURESS AND YOU WISH TO REVOKE THAT CONSENT, YOU MUST:
1. NOTIFY THE ADOPTION ENTITY, __________________________, at _____________________________, BY WRITING A LETTER, THAT YOU WISH TO WITHDRAW YOUR CONSENT; AND
2. PROVE IN COURT THAT THE CONSENT WAS OBTAINED BY FRAUD OR DURESS.
D. I consent, release, and give up permanently, of my own free will, my parental rights to this minor child, for the purpose of adoption.
E. I waive service of process and any further notice of the termination of parental rights and adoption proceedings pertaining to this child.
F. I understand I have the right to know the identity of the prospective adoptive parent(s) of this child. I waive this right and I am signing this consent freely and voluntarily without knowing, and my consent is not conditioned upon knowing, the prospective adoptive parent(s) identities.
I understand that I am swearing or affirming under oath to the truthfulness of the claims made in this consent and waiver and that the punishment for knowingly making a false statement includes fines and/or imprisonment.