CONSENT TO ADOPTION AND SURRENDER OF PARENTAL RIGHTS

(Commonwealth of Massachusetts)

[// GUIDANCE: This template is drafted for use in a private‐placement or agency‐assisted adoption under Massachusetts law. It is designed to be filed with the Probate and Family Court pursuant to M.G.L. c. 210. Counsel should customize all bracketed items, verify factual recitals, and confirm court-specific filing protocols before execution.]

I. DOCUMENT HEADER

1. Title
   Consent to Adoption and Surrender of Parental Rights (the “Consent”)

2. Parties
   a. “[CONSENTING PARENT FULL LEGAL NAME]”, residing at [ADDRESS] (the “Consenting Parent”).
   b. “[PROSPECTIVE ADOPTIVE PARENT(S)]” (collectively, the “Adoptive Parent(s)”) — identified for notice purposes only.
   c. “[CHILD LEGAL NAME]”, born on [DATE OF BIRTH] in [CITY/STATE] (the “Child”).

3. Effective Date
   This Consent becomes effective on the date it is signed and notarized in accordance with Section III.A(3) (the “Effective Date”).

4. Governing Law and Jurisdiction
   This Consent is governed by the laws of the Commonwealth of Massachusetts, including but not limited to M.G.L. c. 210, §§ 2–4 (“Massachusetts Adoption Law”).
   Any proceedings arising from or relating to this Consent shall be commenced exclusively in the Massachusetts Probate and Family Court having venue over the domicile of the Child (the “Court”).

II. DEFINITIONS

For ease of reference, the following terms have the meanings set forth below. Defined terms appear capitalized throughout this Consent.

1. “Child” – The minor identified in Section I.2(c).
2. “Consenting Parent” – The individual executing and surrendering parental rights under this Consent.
3. “Adoptive Parent(s)” – The individual(s) seeking to adopt the Child.
4. “Court” – As defined in Section I.4.
5. “Counseling” – Pre-consent counseling provided by a licensed social worker, adoption agency representative, or qualified mental-health professional that addresses the legal and personal consequences of adoption, as required by Massachusetts Adoption Law and 110 CMR 7.000 et seq.
6. “Revocation Period” – The limited window during which the Consenting Parent may petition the Court to withdraw this Consent, as set forth in Section III.C.
7. “Surrender” – The permanent relinquishment of all legal, custodial, and residual parental rights to the Child.

III. OPERATIVE PROVISIONS

A. Consent and Surrender
1. Irrevocable Consent. Subject to the Revocation Period described in Section III.C, the Consenting Parent hereby unconditionally and voluntarily:
a. Consents to the adoption of the Child by the Adoptive Parent(s); and
b. Surrenders and relinquishes to the Adoptive Parent(s) and/or the Department of Children and Families (“DCF”), as applicable, all parental rights, duties, privileges, and obligations with respect to the Child, including the right to custody, control, visitation, and inheritance.
2. Waiver of Further Notice. The Consenting Parent waives all further notice of any adoption, guardianship, or name-change proceedings concerning the Child, except as required by the Court.
3. Timing Certification. The Consenting Parent certifies that:
a. The Child is at least four (4) calendar days old on the date of execution of this Consent, as mandated by M.G.L. c. 210, § 2; and
b. This Consent is executed no earlier than those four days, and no person has requested or required its execution prior to that statutory waiting period.

B. Counseling Certification
1. Receipt or Waiver. The Consenting Parent affirms that he/she/they:
a. Has received Counseling regarding the meaning and consequences of adoption, OR
b. Has been advised of the right to such Counseling and voluntarily waives it.
2. Documentation. A Counseling Acknowledgment in the form attached as Exhibit A is incorporated herein by reference.

C. Revocation
[// GUIDANCE: Massachusetts law does NOT grant an automatic, unconditional revocation right for private-placement adoptions. The provision below reflects the current statutory framework while affording a limited, court-controlled mechanism consistent with best practice.]
1. Permissible Withdrawal. The Consenting Parent may seek to withdraw this Consent only by filing a verified petition with the Court (the “Revocation Petition”) within thirty (30) calendar days after the Effective Date or prior to the entry of the adoption decree, whichever occurs first.
2. Standard of Review. The Court may grant a Revocation Petition solely upon a factual finding that withdrawal of consent is in the Child’s best interests.
3. Finality. If no Revocation Petition is timely filed—or if the Court denies such petition—this Consent becomes final, irrevocable, and binding on all parties.

D. Additional Acknowledgments
1. Independent Counsel. The Consenting Parent has been advised of the right to consult independent legal counsel before signing and:
a. Has consulted such counsel, OR
b. Knowingly waives that right.
2. Voluntariness. The Consenting Parent executes this Consent freely and voluntarily, without fraud, duress, coercion, or undue influence of any kind.
3. Full Disclosure. The Consenting Parent has received full disclosure of his/her/their legal rights and the consequences of surrender and adoption.
4. English Language and Comprehension. This Consent has been read and explained to the Consenting Parent in [SPECIFY LANGUAGE]. The Consenting Parent fully understands its terms.

IV. REPRESENTATIONS & WARRANTIES

The Consenting Parent represents and warrants to the Court and, where applicable, to DCF and the Adoptive Parent(s) that:

1. Legal Capacity. He/she/they is of legal age and sound mind and is the Child’s [mother/father/parent] as a matter of Massachusetts law.
2. Exclusive Parental Rights. No other person possesses custodial or parental rights to the Child except as disclosed to the Court.
3. No Pending Litigation. There is no pending litigation, restraining order, or guardianship proceeding that would impair the validity or enforceability of this Consent, other than as stated in any attached schedule.
4. Accuracy. All information provided herein and in any supporting documentation is true, complete, and correct in every material respect.
5. Survival. The representations and warranties in this Section survive execution and remain enforceable notwithstanding any subsequent adoption decree.

V. COVENANTS & RESTRICTIONS

1. Cooperation. The Consenting Parent shall execute any additional documents reasonably requested by the Court, DCF, or the Adoptive Parent(s) to effectuate the adoption.
2. No Interference. Except as permitted under Section III.C, the Consenting Parent covenants not to interfere with, contest, or otherwise impede the adoption proceedings.

VI. DEFAULT & REMEDIES

1. Event of Default. A breach of any covenant, representation, or warranty herein constitutes a default.
2. Remedies. In addition to any remedy available at law or equity, the Court may:
   a. Deny a Revocation Petition filed in bad faith;
   b. Impose sanctions or award attorney’s fees; and/or
   c. Issue any protective orders necessary to safeguard the Child’s welfare.
3. Cure. Because time is of the essence, remedies under this Section may be invoked without prior notice or cure period where the Court determines that immediate action is required to protect the Child.

VII. RISK ALLOCATION

[Reserved – Indemnification and limitation-of-liability provisions are inapplicable to a parental consent under Massachusetts Adoption Law.]

VIII. DISPUTE RESOLUTION

1. Governing Law. Massachusetts law governs all disputes arising under this Consent.
2. Exclusive Forum. The Probate and Family Court referenced in Section I.4 has exclusive subject-matter jurisdiction.
3. Arbitration. Arbitration is not available for disputes arising out of this Consent.
4. Jury Waiver. Jury trial is unavailable in the Probate and Family Court; all matters shall be resolved by a judge sitting without a jury.
5. Injunctive Relief. The Court retains full authority to enter any orders necessary to protect the Child, including orders of permanent placement.

IX. GENERAL PROVISIONS

1. Entire Agreement. This Consent constitutes the entire agreement of the parties concerning the subject matter and supersedes all prior oral or written statements.
2. Amendment & Waiver. No amendment or waiver is valid unless in a writing signed by the Consenting Parent and approved by the Court.
3. Severability. If any provision is held unenforceable, the remaining provisions shall remain in full force to the maximum extent permitted by law.
4. Successors & Assigns. This Consent binds the Consenting Parent and inures to the benefit of the Adoptive Parent(s), DCF (if applicable), and the Child.
5. Counterparts & Electronic Signatures. This Consent may be executed in counterparts, each of which is deemed an original. Facsimile, PDF, and electronically-signed counterparts are legally effective.
6. Headings. Section headings are for convenience only and shall not affect interpretation.

X. EXECUTION BLOCK

[// GUIDANCE: Massachusetts requires that the parent’s signature be notarized. Some courts also require one or two disinterested witnesses. Confirm local practice before finalizing.]

IN WITNESS WHEREOF, the Consenting Parent has executed this Consent on the Effective Date set forth below.

CONSENTING PARENT

Signature of Consenting Parent

Name: _____
Date: _____

NOTARY PUBLIC ACKNOWLEDGMENT

Commonwealth of Massachusetts
County of _______

On this _ day of _, 20, before me, the undersigned notary public, personally appeared ____, proved to me through satisfactory evidence of identification to be the person whose name is signed above, and acknowledged to me that he/she/they executed this instrument voluntarily for its stated purpose.

Notary Public
My commission expires: ____

[Optional Witness Signatures – if required]

Witness #1

Witness #2

EXHIBIT A

Counseling Acknowledgment

I, ____, licensed [social worker/counselor] in the Commonwealth of Massachusetts, hereby certify that on _____________, 20, I provided Counseling to [CONSENTING PARENT] in accordance with 110 CMR 7.000 and related regulations.

Signature: ____
Printed Name: ____
License No.: ____
Date: _________

[// GUIDANCE: Attach any additional schedules—e.g., disclosure of pending matters—behind this page, labeled alphabetically.]