Form 67.5-B Form of agreement of a parent or guardian to an adoption order in a petition for an order freeing a child for adoption under section 18 of the Adoption (Scotland) Act 1978 IN THE COURT OF SESSION in the PETITION of [A.B.] (designation and address) for an Order freeing the child [E.F.] for adoption under section 18 of the Adoption (Scotland) Act 1978 I, , of (address) being a parent [or guardian] of the child, [E.F.], hereby state(1) That I understand that the effect of an adoption order would be to deprive me permanently of the parental responsibilities and parental rights relating to the child and to vest them in the adopters; and that if and when an adoption order is made, I shall have no right to see or get in touch with the child or to have him [or her] returned to me. (2) That I understand that the court cannot make an order freeing a child for adoption without the agreement of each parent or guardian of the child to the making of an adoption order, unless the court dispenses with an agreement on the ground that the person concerned(a) is not known, cannot be found or is incapable of giving agreement; (b) is withholding agreement unreasonably; (c) has persistently failed, without reasonable cause, to fulfil one or other of the following parental responsibilities in relation to the child(i) the responsibility to safeguard and promote the child’s health, development and welfare; or (ii) if the child is not living with him, the responsibility to maintain personal relations and direct contact with the child on a regular basis; or (d) has seriously ill-treated the child, whose reintegration into the same household as the parent or guardian is, because of the serious ill-treatment or for other reasons, unlikely. (3) That I also understand that when the hearing on the petition to determine the application for an order freeing the child for adoption is heard, this document may be used as evidence of my agreement to the making of an adoption order unless I inform the court that I no longer agree. (4) That I freely, and with full understanding of what is involved, agree unconditionally to the making of an adoption order. (5) [That I have been given an opportunity of making a declaration that I prefer not to be involved in future questions concerning the adoption of the child. I understand that if I make such a declaration I will not be told when the child has been adopted or whether he has been placed for adoption. I also understand that I will not be able to apply for a revocation of the
order freeing the child for adoption if I make such a declaration. I hereby declare freely, and with full understanding of what is involved, that I do not wish to be involved in future questions concerning the adoption of the child.] [or That I have been given an opportunity of making a declaration that I prefer not to be involved in future questions concerning the adoption of the child, and the effect of making such a declaration has been explained to me. I do not wish to make such declaration.]
[(6) That I have not received or given any payment or reward for, or in consideration of, the adoption of the child, for any agreement to the making of an adoption or consent to the making of an application for an order freeing the child for adoption, for placing the child for adoption with any person or making any arrangements for adoption of the child, other than a payment to an adoption agency for their expenses incurred in connection with the adoption.] (Signed by parent or guardian) This agreement was signed by (Signed) (Designation) (Address) before me at on the day of