Adoption Consent Form

ACT OF PARENTAL CONSENT AND SURRENDER FOR ADOPTION

(State of Louisiana – Private/Agency Placement)

TABLE OF CONTENTS

1. Document Header
2. Definitions

3. Operative Provisions
   3.1 Consent & Surrender
   3.2 Transfer of Custody
   3.3 Counseling Acknowledgment
   3.4 Revocation Rights
   3.5 Finality of Surrender

4. Representations & Warranties

5. Covenants & Restrictions
6. Default & Remedies
7. Risk Allocation (Not Applicable)
8. Dispute Resolution
9. General Provisions
10. Execution Block & Notarial Acknowledgment

1. DOCUMENT HEADER

Title: Act of Parental Consent and Surrender for Adoption
Parties:
• [FULL LEGAL NAME OF BIRTH MOTHER] (“Birth Mother”)
• [FULL LEGAL NAME OF BIRTH FATHER] (“Birth Father”) (if applicable)
• [FULL LEGAL NAME OF ADOPTION AGENCY] or [NAME(S) OF PROSPECTIVE ADOPTIVE PARENT(S)] (“Custodian”)
Child: [INFANT/CHILD’S NAME OR “Baby [Surname]”] (“Child”)
Effective Date: [DATE OF EXECUTION] (“Effective Date”)
Governing Law: Louisiana Children’s Code and other applicable Louisiana law (“state_adoption_law”).
Designated Forum: [PARISH] Parish Juvenile Court (“state_family_court”).

Recitals
A. Birth Parent(s) are the biological parent(s) of Child, born on [DATE OF BIRTH] in [PARISH], Louisiana.
B. Birth Parent(s) desire permanently to surrender all parental rights to, and consent to the adoption of, Child in accordance with Louisiana law.
C. Custodian desires to accept physical and legal custody of Child pending entry of a final decree of adoption.
D. The Parties enter into this Act to memorialize their rights and obligations as of the Effective Date.

2. DEFINITIONS

For purposes of this Act, capitalized terms have the meanings set forth below.

“Act” means this Act of Parental Consent and Surrender for Adoption, as amended from time to time in accordance with Section 9.1.

“Agency” means the licensed child-placing agency identified in the Document Header, if applicable.

“Birth Parent(s)” means, individually or collectively, the Birth Mother and Birth Father.

“Child” has the meaning given in the Document Header.

“Custodian” means the Agency or the Prospective Adoptive Parent(s) who assume legal and physical custody of Child pursuant to Section 3.2.

“Effective Date” has the meaning stated in the Document Header.

“Revocation Period” has the meaning set forth in Section 3.4(a).

3. OPERATIVE PROVISIONS

3.1 Consent & Surrender

(a) Birth Parent(s) hereby unconditionally:
i. Surrender and relinquish all parental rights, custody, and control over Child; and
ii. Consent to the permanent adoption of Child by the Prospective Adoptive Parent(s) or such person(s) as the Court may approve.

(b) Birth Mother affirms that this Act is executed not earlier than seventy-two (72) hours after Child’s live birth.

(c) Birth Father affirms that Louisiana law permits execution of this Act at any time, including prior to Child’s birth.

3.2 Transfer of Custody

Upon execution of this Act, physical and legal custody of Child shall transfer to Custodian, who shall thereafter exercise all rights and assume all duties of temporary tutorship pending finalization of the adoption.

3.3 Counseling Acknowledgment

(a) Birth Parent(s) acknowledge receipt of written notice that they are entitled to at least three (3) hours of post-placement counseling by a licensed mental-health professional of their choice, the reasonable cost of which shall be borne by Custodian.
(b) Birth Parent(s): [___] Accept ☐ Waive such counseling (circle one).

3.4 Revocation Rights

(a) Birth Parent(s) may revoke this Act within five (5) calendar days after the later of (i) the date of execution or (ii) Child’s date of birth (the “Revocation Period”).
(b) Revocation must be made by a written, notarized instrument delivered to Custodian and filed with the Clerk of Court within the Revocation Period.
(c) Upon timely revocation, legal custody of Child shall immediately revert to Birth Parent(s), and Custodian shall promptly return Child.

3.5 Finality of Surrender

If no timely revocation is effected under Section 3.4, this Act becomes irrevocable and permanent on the first calendar day immediately following expiration of the Revocation Period, and Birth Parent(s) forever waive any and all rights to contest the adoption.

4. REPRESENTATIONS & WARRANTIES

4.1 By Birth Parent(s)
(a) Age & Capacity. Each Birth Parent is at least [18] years old and legally competent.
(b) Sole Parental Rights. Each Birth Parent has not previously relinquished parental rights to any other person or entity.
(c) Voluntariness. Execution of this Act is knowing, voluntary, and free from duress, coercion, or undue influence.
(d) No Consideration. No improper payment or inducement has been offered or accepted other than lawful adoption-related expenses.
(e) Full Disclosure. All material information concerning Child’s health, genetics, and background known to Birth Parent(s) has been disclosed.

4.2 By Custodian
(a) Licensing. If Custodian is an Agency, it is duly licensed by the Louisiana Department of Children & Family Services.
(b) Background Compliance. Prospective Adoptive Parent(s) have satisfied all home-study, background-check, and investigative requirements of Louisiana law.
(c) Financial Responsibility. Custodian will pay lawful and reasonable adoption-related expenses, including counseling described in Section 3.3.

4.3 Survival
The representations and warranties in this Section 4 survive execution of this Act and the issuance of any final adoption decree.

5. COVENANTS & RESTRICTIONS

5.1 Non-Interference. After the Revocation Period, Birth Parent(s) shall not:
(i) institute or assist any legal proceeding contesting Custodian’s custody or the adoption of Child;
(ii) contact Child, Custodian, or Prospective Adoptive Parent(s) except as expressly permitted by a written, court-approved Post-Adoption Contact Agreement, if any.

5.2 Cooperation. Each Party shall execute any additional documents reasonably necessary to effectuate the intent of this Act and comply with court or agency procedures.

5.3 Confidentiality. All identifying information shall be maintained in confidence except as disclosed in court filings or required by law.

6. DEFAULT & REMEDIES

6.1 Events of Default
(a) Failure to comply with Section 3.4 (timely return of Child upon revocation).
(b) Breach of Section 5 covenants.

6.2 Notice & Cure
The non-defaulting Party shall provide written notice specifying the default. The defaulting Party shall have three (3) calendar days to cure, if curable.

6.3 Remedies
In addition to any remedy available at law or in equity:
(a) Specific Performance. The Parties acknowledge monetary damages are inadequate; specific performance may be ordered.
(b) Attorney Fees. The prevailing Party in any enforcement action shall be entitled to reasonable attorney fees and costs.

7. RISK ALLOCATION (Not Applicable)

8. DISPUTE RESOLUTION

8.1 Governing Law. This Act is governed by and construed in accordance with Louisiana law (“state_adoption_law”).

8.2 Exclusive Forum. Any proceeding arising under or relating to this Act shall be brought exclusively in the [PARISH] Parish Juvenile Court (“state_family_court”).

8.3 Jury Waiver. Family-court proceedings in Louisiana are tried without a jury as a matter of law (“no_jury_family_court”).

8.4 Injunctive Relief. Nothing in this Act limits the Court’s authority to issue temporary or permanent orders affecting custody or placement (“permanent_placement”).

9. GENERAL PROVISIONS

9.1 Amendments & Waivers. Any amendment or waiver must be in writing, signed by all Parties, and approved by the Court.

9.2 Assignment. Neither this Act nor any rights hereunder may be assigned by Birth Parent(s). Custodian may assign to a successor agency or guardian only with Court approval.

9.3 Successors & Assigns. This Act binds and inures to the benefit of the Parties and their respective heirs, legal representatives, and permitted assigns.

9.4 Severability. If any provision is held invalid, the remaining provisions remain enforceable to the fullest extent permitted by law.

9.5 Integration. This Act constitutes the entire agreement among the Parties regarding the subject matter and supersedes all prior agreements or understandings.

9.6 Counterparts; Electronic Signatures. This Act may be executed in counterparts and by electronic signature, each of which is deemed an original.

10. EXECUTION BLOCK & NOTARIAL ACKNOWLEDGMENT

10.1 Birth Mother

_________________________________________
[PRINTED NAME]
Date: ___________________

10.2 Birth Father (if applicable)

_________________________________________
[PRINTED NAME]
Date: ___________________

10.3 Custodian

☐ Licensed Adoption Agency
☐ Prospective Adoptive Parent(s)

_________________________________________
[AUTHORIZED SIGNATORY / PRINTED NAME & TITLE]
Date: ___________________

Witnesses

1. _______________________________________
   [PRINTED NAME] – Witness
   Date: ___________________

2. _______________________________________
   [PRINTED NAME] – Witness
   Date: ___________________

Notary Public

STATE OF LOUISIANA
PARISH OF __________________

On this ____ day of ____________, 20____, before me, the undersigned Notary Public, personally appeared the individual(s) whose name(s) are subscribed above, each known to me or satisfactorily proven to be the person(s) described herein, who executed the foregoing Act of Parental Consent and Surrender for Adoption as a free and voluntary act for the purposes therein contained.

IN WITNESS WHEREOF, I hereunto set my hand and official seal.

_________________________________________
Notary Public
Notary ID No.: ___________________________
My Commission Expires: _________________