1. I understand English, or this consent form has been translated into __________, a language that I understand.

3. My date of birth is __________. I am ___ years old.

4. I understand that __________ have asked to adopt me.

5. I have a lawyer whose name and telephone number are __________. I have met with my lawyer who has gone over this consent form with me and explained to me what it means to be adopted.

6. I understand that if I agree to be adopted, and I am adopted, __________ will become my parents, and I will become their child.

7. I understand that I do not have to agree to be adopted. If I do not agree, the judge cannot approve the adoption. If the adoption is not approved, and I am not adopted by someone else, a judge will decide where I will live.

8. I voluntarily and of my own free will agree to being adopted by __________. I understand that if they are not able to complete the adoption, this consent form will no longer be valid and can no longer be used.

9. I understand that if I change my mind and do not want to be adopted, I must tell my lawyer, my social worker, or the judge immediately. I will have to sign a written statement or tell the judge in court that I do not want to be adopted before the adoption order is signed by a judge. This is called a revocation of consent.

10. I understand that when I am at least 21 years old, my birth parents or I may apply to the Secretary of the Maryland Department of Health to get certain birth and adoption records. If I do not want information about me to be given to my birth parents, I have the right to file a form called a “disclosure veto.” I have been given a form that I may use if I want to file a disclosure veto.

11. I understand that when I am at least 21 years old, my birth parents, my siblings, or I may apply to the Director of the Social Services Administration of the Maryland Department of Human Resources for adoption search, contact, and reunion services.

12. I have read this consent form or have had it read and explained to me in a language that I understand. I understand the meaning of this consent form.

13. I have not been promised anything in return for agreeing to be adopted.

14. I have signed this consent form of my own free will.

15. I understand that I will be given a copy of this signed consent form.

I solemnly affirm under the penalties of perjury that the contents of this consent to adoption form are true to the best of my knowledge, information, and belief.