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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.



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Signature of Parent                                                                            Date

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Signature of Parent                                                                            Date

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