RELINQUISHMENT
OF INFANT BY PARENTS
We,
_______________ and _______________, the parents having the exclusive right to
custody and control of ____________________, a _______________ (Male/Female) infant born in
________________ (Hospital) at
_______________________________ (Address)
on ___________ (Date), hereby
voluntarily do assign and release custody of the above-named infant to
______________________________ (Person/Institution)
of _____________________________________________________________ (Address).
We
hereby agree that _________________________________ (Person/Institution) is to assume custody of the infant
____________________________, for the purpose of placing ______ (Him/Her) in a suitable, adoptive family
home.
We
hereby authorize ____________________________________ (Person/Institution) to undertake all the
appropriate steps necessary to effect the legal adoption of the infant,
___________________________________, the same as if we were present, and we
hereby waive notice of any proceeding for the adoption of the infant by any
family with whom it may be placed by ________________________________ (Person/Institution).
We,
_________________ and __________________, as parents of _______________, hereby
assert the infant is of sound body and mind.
If it is discovered that ______ (he
or she) is not of sound body and mind when received by
_______________________ (Person/Institution),
this relinquishment agreement shall become void and of no further effect, and
we shall, thereupon, accept the return of the above-named infant.
___________________________________ ___________
Signature
of Parent Date
____________________________________ ___________
Signature
of Parent Date