ADOPTION CONSENT FORM
(State of Tennessee)
[// GUIDANCE: This template is designed for use in private‐placement, agency, or related adoptions governed exclusively by Tennessee law. Customize all bracketed items and confirm statutory compliance before execution.]
TABLE OF CONTENTS
- Document Header
- Definitions
- Operative Provisions
3.1 Surrender of Parental Rights
3.2 Consent to Adoption
3.3 Timing Requirements
3.4 Revocation Rights
3.5 Counseling Acknowledgment - Representations & Warranties
- Covenants & Restrictions
- Default & Remedies
- Risk Allocation (Not Applicable)
- Dispute Resolution
- General Provisions
- Execution Block
1. DOCUMENT HEADER
THIS ADOPTION CONSENT FORM (this “Consent”) is entered into and made effective as of [EFFECTIVE DATE] (the “Effective Date”) by and among the following parties:
- “[BIOLOGICAL PARENT 1 FULL NAME],” a natural parent of the Child (as defined below);
- “[BIOLOGICAL PARENT 2 FULL NAME]” (if applicable), a natural parent of the Child (each, a “Biological Parent” and, collectively, the “Biological Parents”);
- “[PROSPECTIVE ADOPTIVE PARENT 1 FULL NAME]” and “[PROSPECTIVE ADOPTIVE PARENT 2 FULL NAME]” (if applicable), (each, a “Prospective Adoptive Parent” and, collectively, the “Prospective Adoptive Parents”); and
- “[LICENSED CHILD-PLACING AGENCY FULL LEGAL NAME],” a Tennessee-licensed child-placing agency (the “Agency”), if any.
RECITALS
A. The Biological Parents are the legal parent(s) of the minor child identified herein.
B. The Prospective Adoptive Parents desire to adopt the Child.
C. Tennessee adoption law requires that each legal parent execute a written surrender and consent in accordance with statutory formality, timing, and counseling mandates.
D. The parties intend that this Consent satisfy all applicable Tennessee statutory requirements and be immediately enforceable upon execution and expiration of the statutory revocation period.
NOW, THEREFORE, in consideration of the mutual promises set forth herein and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows.
2. DEFINITIONS
For purposes of this Consent, capitalized terms have the meanings set forth below:
“Act” means the Tennessee statutes governing adoption and surrender of parental rights, as amended from time to time.
“Child” means the minor child known as [CHILD’S FULL LEGAL NAME], born on [DATE OF BIRTH] in [CITY/COUNTY], Tennessee.
“Consent” or “Surrender” means this instrument by which a Biological Parent voluntarily and irrevocably (subject only to Section 3.4) relinquishes all parental rights to the Child and consents to the Child’s adoption by the Prospective Adoptive Parents.
“Counseling” means the statutorily required counseling offered to each Biological Parent prior to execution of this Consent.
“Court” means the [COUNTY] [Chancery/Juvenile] Court of the State of Tennessee having jurisdiction over the adoption proceeding.
“Revocation Period” has the meaning given in Section 3.4.
“Waiting Period” has the meaning given in Section 3.3(a).
3. OPERATIVE PROVISIONS
3.1 Surrender of Parental Rights
Each Biological Parent hereby unconditionally surrenders, relinquishes, and forever terminates all parental rights, custody, and control with respect to the Child, including all rights of inheritance, visitation, decision-making, and any other legal or equitable incidents of parenthood.
3.2 Consent to Adoption
Each Biological Parent expressly and irrevocably (subject only to Section 3.4) consents to the adoption of the Child by the Prospective Adoptive Parents and authorizes the Court to enter a final order of adoption in favor of the Prospective Adoptive Parents at the appropriate time.
3.3 Timing Requirements
(a) Waiting Period. No Biological Parent shall execute this Consent earlier than seventy-two (72) hours after the Child’s birth (the “Waiting Period”).
(b) Certification. By signing below, each signatory certifies that the Waiting Period has expired and that this Consent is executed in strict compliance with the Act.
[// GUIDANCE: If the surrender is executed more than five (5) days post-birth, delete subsection (b) or adjust language accordingly.]
3.4 Revocation Rights
(a) Revocation Period. A Biological Parent may revoke this Consent, for any reason, by delivering a written, signed revocation to the Court (or, if applicable, the Agency) no later than midnight on the tenth (10th) calendar day following the date on which such Biological Parent executed this Consent (the “Revocation Period”).
(b) Manner of Revocation. Any revocation must:
(i) reference this Consent and the Child by name;
(ii) clearly state the Biological Parent’s intent to revoke; and
(iii) be personally delivered, or sent via certified mail, return receipt requested, to the Court (and the Agency, if any) within the Revocation Period.
(c) Effect of Revocation. Upon timely revocation, this Consent shall be null and void ab initio solely with respect to the revoking Biological Parent, and all parental rights shall be restored automatically without further order of the Court.
(d) Expiration. If no timely revocation is received, this Consent becomes final and irrevocable upon expiration of the Revocation Period.
3.5 Counseling Acknowledgment
Each Biological Parent acknowledges that:
(a) the Counseling required under the Act has been offered and provided;
(b) the contents of this Consent, the consequences of surrender, and the Revocation Period have been fully explained in a face-to-face session with a licensed counselor or attorney; and
(c) the Biological Parent had the right to decline Counseling but chose to [ACCEPT/DECLINE] such Counseling.
4. REPRESENTATIONS & WARRANTIES
4.1 By Each Biological Parent
(a) Authority. Such Biological Parent is the legal [mother/father] of the Child and has full authority to surrender parental rights.
(b) Capacity. Such Biological Parent is at least eighteen (18) years of age, is not under the influence of intoxicants or controlled substances, and is not acting under duress, coercion, or undue influence.
(c) No Prior Termination. No court has previously terminated such Biological Parent’s rights to the Child.
(d) Disclosure. All information provided to the Prospective Adoptive Parents or Agency regarding the Child’s health, social, and genetic history is complete and accurate to the best of such Biological Parent’s knowledge.
4.2 By Prospective Adoptive Parents
(a) Eligibility. Each Prospective Adoptive Parent meets all statutory eligibility requirements for adoption in Tennessee.
(b) Resources. They have the financial, emotional, and physical resources to care for the Child.
4.3 Survival
All representations and warranties survive execution of this Consent and the entry of any decree of adoption.
5. COVENANTS & RESTRICTIONS
5.1 No Contact During Revocation Period
Except as expressly permitted by written agreement approved by the Court, a Biological Parent shall not contact the Child or Prospective Adoptive Parents during the Revocation Period.
5.2 Confidentiality
Each party shall maintain the confidentiality of any identifying information as required by the Act and orders of the Court.
5.3 Cooperation
The parties shall cooperate fully in all proceedings necessary to finalize the adoption, including appearances before the Court.
6. DEFAULT & REMEDIES
6.1 Event of Default
A party’s material breach of Sections 3, 4, or 5 constitutes an “Event of Default.”
6.2 Notice and Cure
Upon an Event of Default, any non-breaching party shall give written notice specifying the default. If the default is not cured within five (5) calendar days, the non-breaching party may seek appropriate relief from the Court.
6.3 Remedies
The Court may:
(a) enforce specific performance;
(b) issue any necessary injunctive relief to protect the Child’s best interests and permanent placement; and
(c) award reasonable attorney’s fees and costs to the prevailing party.
[// GUIDANCE: Monetary damages are generally disfavored in family-law contexts; equitable remedies predominate.]
7. RISK ALLOCATION
Intentionally Omitted. No indemnification, liability limitation, or insurance obligation applies to this Consent.
8. DISPUTE RESOLUTION
8.1 Governing Law
This Consent and any related proceedings shall be governed by the laws of the State of Tennessee, without regard to conflict-of-laws principles.
8.2 Exclusive Forum
The parties irrevocably submit to the exclusive jurisdiction of the [COUNTY] [Chancery/Juvenile] Court of Tennessee for all matters arising under or relating to this Consent.
8.3 Arbitration
Arbitration is not available for disputes arising out of or relating to this Consent, which must be resolved exclusively by the Court.
8.4 Jury Waiver
No jury trial is available in adoption proceedings; the parties acknowledge that the Court will decide all issues of fact and law.
8.5 Injunctive Relief
Nothing herein limits the Court’s authority to enter all necessary injunctive or equitable relief to ensure the Child’s permanent placement and best interests.
9. GENERAL PROVISIONS
9.1 Amendments
No amendment or waiver of any provision of this Consent is effective unless set forth in a writing executed by all affected parties and approved by the Court.
9.2 Assignment
Neither this Consent nor any rights hereunder may be assigned or delegated without prior written Court approval.
9.3 Successors and Assigns
This Consent binds and benefits the parties and their respective heirs, legal representatives, and permitted assigns.
9.4 Severability
If any provision is held unenforceable, the remaining provisions shall remain in full force, and the unenforceable provision shall be reformed to the minimum extent necessary to achieve its intent.
9.5 Integration
This Consent, together with any attachments required by statute, constitutes the entire agreement of the parties regarding the subject matter and supersedes all prior oral or written agreements.
9.6 Counterparts; Electronic Signatures
This Consent may be executed in multiple counterparts, each of which is deemed an original, and all of which constitute one instrument. Signatures transmitted by facsimile, email (PDF), or other electronic means are valid and binding.
10. EXECUTION BLOCK
IN WITNESS WHEREOF, the parties have executed this Consent as of the Effective Date.
BIOLOGICAL PARENT(S)
[BIOLOGICAL PARENT 1 NAME]
Date: _________
[BIOLOGICAL PARENT 2 NAME] (if applicable)
Date: _________
PROSPECTIVE ADOPTIVE PARENT(S)
[PROSPECTIVE ADOPTIVE PARENT 1 NAME]
Date: _________
[PROSPECTIVE ADOPTIVE PARENT 2 NAME] (if applicable)
Date: _________
AGENCY REPRESENTATIVE (if any)
[AUTHORIZED AGENCY REPRESENTATIVE NAME & TITLE]
Date: _________
ATTORNEY CERTIFICATION
I, the undersigned Tennessee-licensed attorney, certify that I have fully explained the legal consequences of this Consent, including the Waiting Period, Revocation Period, and permanent termination of parental rights.
[ATTORNEY NAME], TN Bar # __
Date: _________
NOTARY PUBLIC
State of Tennessee )
County of [____] )
On this _ day of _, 20__, before me, a Notary Public of said State, personally appeared the above-signed individual(s), known to me (or satisfactorily proven) to be the person(s) whose name(s) are subscribed to this instrument, and acknowledged that they executed the same for the purposes therein contained.
Notary Public
My Commission Expires: ___
JUDICIAL ACKNOWLEDGMENT (Optional/If Required)
The Court finds that this Consent complies with Tennessee law, that all statutory requirements have been satisfied, and that the surrender and consent are knowing, voluntary, and in the best interest of the Child. Accordingly, the Court accepts and approves this Consent.
Judge of the [COUNTY] [Chancery/Juvenile] Court
Date: _________
[// GUIDANCE: Attach any statutorily mandated disclosure statements, medical/social history forms, and counseling certificates as separate schedules labeled “Exhibit A,” “Exhibit B,” etc., and reference them in Section 9.5.]