Adoption Consent Form

**PARENTAL CONSENT TO ADOPTION

AND SURRENDER OF PARENTAL RIGHTS
(State of Alaska)**

TABLE OF CONTENTS

I. DOCUMENT HEADER

1. Parties.
   (a) “Consenting Parent”: [INSERT FULL LEGAL NAME], biological [mother/father] of the minor child identified below.
   (b) “Child”: [INSERT CHILD’S FULL LEGAL NAME], born [DATE OF BIRTH].
   (c) “Prospective Adoptive Parent(s)” (if identified): [INSERT NAME(S)] (collectively, the “Adoptive Parent”).
   (d) “Licensed Child-Placing Agency” (if applicable): [AGENCY NAME], Alaska license no. [####] (the “Agency”).

2. Recitals.
   WHEREAS, Consenting Parent is the legal [mother/father] of Child and desires permanently to surrender all parental rights to facilitate Child’s adoption;
   WHEREAS, Alaska law requires written consent of a living parent before an adoption may be granted, Alaska Stat. § 25.23.050; and
   WHEREAS, Consenting Parent has received mandatory counseling and statutory disclosures and now executes this Consent in accordance with applicable law;

3. Effective Date; Governing Law.
   This Consent becomes effective on the date it is signed, notarized, and filed with the Alaska [County] Superior Court, Family Division (the “Effective Date”) and is governed by the laws of the State of Alaska without regard to conflict-of-laws principles.

II. DEFINITIONS

For ease of reference, the following terms have the meanings set forth below and apply throughout this Consent:

“Agency” – The Licensed Child-Placing Agency named in Section I(1)(d) or any lawful successor.

“Counseling” – The pre-consent counseling mandated under Alaska adoption law and further described in Section III(3).

“Court” – The Alaska Superior Court, Family Division, [COUNTY] Judicial District.

“Execution Session” – The in-person proceeding at which the Consenting Parent signs this Consent before a notary public and any statutorily required witnesses or judicial officer.

“Revocation Period” – The statutory period during which Consenting Parent may withdraw this Consent, being ten (10) calendar days after (i) the Effective Date or (ii) the Child’s date of birth, whichever is later, absent a valid judicial relinquishment of that right.

III. OPERATIVE PROVISIONS

3.1 Grant of Consent.
Consenting Parent irrevocably (subject only to Section VI) consents to the adoption of Child by Adoptive Parent, waives further notice of the adoption proceedings after the Revocation Period, and voluntarily surrenders all parental rights, privileges, and obligations concerning Child.

3.2 Timing of Execution.
(a) Minimum Waiting Period. This Consent shall not be executed sooner than forty-eight (48) hours after the Child’s birth unless a court authorizes earlier execution for good cause shown.
(b) Location of Execution. Execution must occur in Alaska before (i) a judge, (ii) a person authorized to take acknowledgments, or (iii) an individual the Court specifically appoints.

3.3 Counseling Acknowledgment.
Consenting Parent acknowledges receipt of not less than two (2) hours of non-directive counseling by a counselor approved by the Agency, focusing on alternatives to adoption, emotional implications, and available support services. A completed Counselor’s Certificate (Exhibit B) shall be attached to this Consent.

3.4 Receipt of Statutory Disclosures.
Consenting Parent affirms receipt of the “Statement of Parental Rights in Adoption” attached as Exhibit A at least seventy-two (72) hours prior to the Execution Session.

3.5 Appointment of Guardian ad Litem.
Consenting Parent hereby consents to the Court’s appointment of a guardian ad litem for Child as deemed appropriate under Alaska R. Prob. P. .

3.6 Post-Placement Communication (Optional).
[OPTIONAL CLAUSE — DELETE IF INAPPLICABLE] Consenting Parent and Adoptive Parent have entered into a Post-Adoption Contact Agreement dated [DATE], incorporated herein by reference, subject to Court approval.

IV. REPRESENTATIONS & WARRANTIES

4.1 Capacity and Authority. Consenting Parent (i) is at least eighteen (18) years old, (ii) is legally competent, and (iii) holds sole legal and physical custody of Child or has the consent of any other individual whose consent is statutorily required.

4.2 No Duress or Undue Influence. Execution of this Consent is voluntary and free from duress, coercion, or undue influence.

4.3 Full Disclosure. Consenting Parent has disclosed to the Agency all information known about Child’s health, background, and heritage to the best of his/her knowledge.

4.4 No Pending Litigation. There is no pending litigation, restraining order, or prior court decree that would prohibit or impede this adoption.

4.5 Survival. The representations and warranties herein survive execution and continue until entry of a final decree of adoption.

V. COVENANTS & RESTRICTIONS

5.1 Cooperation. Consenting Parent shall execute any additional documents reasonably required to effectuate the adoption and will appear at all Court hearings upon reasonable notice within the Revocation Period.

5.2 Non-Interference. After the Revocation Period, Consenting Parent shall not initiate or support any action to contest the adoption except as may be permitted by statute due to fraud or duress.

5.3 Confidentiality. Consenting Parent agrees to keep confidential all identifying information concerning Adoptive Parent, except as otherwise allowed by law or court order.

5.4 Change of Address. Until entry of the final decree of adoption, Consenting Parent shall notify the Agency in writing of any change of mailing address within seven (7) days.

VI. REVOCATION; DEFAULT & REMEDIES

6.1 Revocation Right. Consenting Parent may revoke this Consent only by delivering a written, notarized notice of revocation to the Clerk of the Court and the Agency within the Revocation Period.

6.2 Effect of Revocation. Upon timely revocation, all parental rights revert automatically to Consenting Parent, and Child shall be promptly returned to Consenting Parent unless otherwise ordered by the Court.

6.3 Irrevocability. If no timely revocation is filed, this Consent becomes final, absolute, and irrevocable, except as provided by Alaska law in cases of fraud or duress proven by clear and convincing evidence.

6.4 Default. Any material breach of the covenants herein by Consenting Parent prior to expiration of the Revocation Period constitutes a default, entitling the Agency or Adoptive Parent to seek injunctive relief to maintain Child’s placement.

6.5 Attorney’s Fees. In any action to enforce or set aside this Consent, the prevailing party may recover reasonable attorney’s fees and costs as allowed by Alaska R. Civ. P. 82.

VII. DISPUTE RESOLUTION

7.1 Governing Law. This Consent is governed exclusively by Alaska substantive law and applicable federal law.

7.2 Venue; Forum Selection. Any proceeding arising out of or relating to this Consent shall be filed in the Alaska Superior Court, Family Division, [COUNTY] Judicial District.

7.3 Jury Waiver. By statute, adoption proceedings are non-jury matters; each Party knowingly waives any right to trial by jury.

7.4 Injunctive Relief. The Court retains continuing jurisdiction to enter temporary or permanent injunctive relief to protect the best interests of Child, including maintaining Child’s placement during litigation.

VIII. GENERAL PROVISIONS

8.1 Entire Agreement. This document, together with Exhibits A and B and any approved Post-Adoption Contact Agreement, constitutes the entire agreement of the parties concerning the subject matter and supersedes all prior understandings.

8.2 Amendment & Waiver. No amendment or waiver of any provision herein is effective unless in a writing executed with the same formalities as this Consent and approved by the Court.

8.3 Severability. If any provision is held unenforceable, the remaining provisions remain in full force, and the Court is authorized to reform the unenforceable provision to the minimum extent necessary to render it valid.

8.4 Assignment. This Consent is personal to Consenting Parent and may not be assigned.

8.5 Successors & Assigns. After the final decree of adoption, this Consent binds and benefits the Adoptive Parent, Child, and their respective successors and assigns.

8.6 Counterparts; Electronic Signatures. This Consent may be executed in counterparts, each of which is deemed an original, and signatures transmitted electronically shall be effective to bind the signatory.

IX. EXECUTION BLOCK

Executed as a sealed instrument on the Effective Date indicated below.

On this ___ day of __________, 20__, before me, the undersigned notary public in and for the State of Alaska, personally appeared [CONSENTING PARENT NAME], known to me or satisfactorily proven to be the person whose name is subscribed to this instrument, and acknowledged that he/she executed the same as his/her free and voluntary act for the purposes therein stated.

Notary Public: __________________________
My commission expires: _______________

Exhibit A

STATUTORY RIGHTS DISCLOSURE
(To be attached — Alaska Dept. of Health & Social Services Form 04-AD-900 or its successor)

Exhibit B

COUNSELING CERTIFICATION
(To be attached — executed by licensed counselor verifying completion of mandatory counseling)