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Agreement made on ____________________ (month & day), ________ (year), between _________________________, the ______________________ (mother or father) of _________________________________ (name of child), of ____________

_____________________________________________ (address), here referred to as parent, and _____________________ and ____________________, husband and wife, of ____________________________________________________ (address), here referred to as custodians, and subject to the approval of ________________________ (indicate appropriate governmental agency).


Parent, at the request of custodians, has placed in the care, custody, and control of custodians, at their home at _______________________________________ (address), for a probationary period of _______, the child, _______________________________, who was born ______________________ (month & day), _________ (year), and who is under the care, custody, and control of parent.


Custodians agree as follows:


To receive the child into their home for a trial period of _________________________.

To treat the child as a member of their family and to give _____ (him or her) proper care, and to love, cherish, nurture, and educate ______ (him or her) in a suitable manner, as they would be required to do if _________ (he or she) were their own child.


To notify parent promptly of any change of their address, and in no case leave with or surrender the child to a third party, or remove ____________ (him or her) from the State of _______________ for a period of more than ______ (___) days, without the prior written consent of parent.


Parent shall have, at all reasonable times, access to the child.  Custodians shall relinquish and surrender the child, and release all custody of and right to the child, to parent whenever in the honest opinion of parent such relinquishment, surrender, and release is in the best interest of the child.


Custodians reserve the right to return the child to parent at any time during the probationary period whenever, in the honest opinion of custodians, such return would be in the best interest of the child.


Custodians shall at the expiration of the probationary period, and within ___________ (length of time) thereafter, if the child is then in their custody and they agree that such is in the best interest of all parties involved, commence adoption proceedings to effect the legal adoption of the child.  Custodians shall pay all costs incident to such proceedings.


In witness whereof, the parties hereto have signed this agreement at _______________ _______________ (designate place of execution) the day and year first above written.


___________________________________                                          ______________

(Signature)                                                                                                                        (Date)


___________________________________                                          ______________

(Signature)                                                                                                                        (Date)


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