A. What a Consent Means. If you sign this consent, you are agreeing and acknowledging that the court may, and likely will, enter an order that:

C. Post-Adoption Agreement. If you have made a written agreement with the adoptive parents for future contact with them or the child (known as a post-adoption agreement), a copy of that agreement must be attached to the signed consent form. If you have a post-adoption agreement, and, after the adoption, the adoptive parents do not do what they agreed to do, it will not affect your consent to the guardianship or the adoption. If that happens, however, you have the right to ask a judge to make them do what they agreed to do. The judge can order you and the adoptive parents to go to mediation, order the adoptive parents to do what they agreed to do, or change the agreement if the judge decides that it is in the child's best interest.

D. Consent. If you decide to sign the consent form, you will have two choices:

E. Effect of Post-Adoption Agreement. If you have a post-adoption agreement, you will keep only the rights the agreement gives you. See Paragraph C. Violation of the agreement will not affect your consent or the adoption.

F. Filing of Consent. After you sign the consent form, the person or agency to whom you give the form must file it in the Juvenile Court promptly. If a guardianship case has been filed, it will be filed in the guardianship case. If a guardianship case has not been filed, it will be filed in the child's CINA (Child in Need of Assistance) case. When it is filed, a copy of the filed consent form will be sent to you at the address you list at the end of the consent form. It is your responsibility to let the court know if your address changes.

I. Compensation. Under Maryland law, you are not allowed to charge or receive money or compensation of any kind for the placement for adoption of your child or for your agreement to the adoptive parent having custody of your child, except that reasonable and customary charges or fees for adoption counseling, hospital, legal, or medical services may be paid.

J. Access to Birth and Adoption Records. When your child is at least 21 years old, your child, your child's other parent, or you may apply to the Maryland Secretary of the Department of Health for access to certain birth and adoption records. If you do not want information about you to be disclosed (given) to that person, you have the right to prevent disclosure by filing a disclosure veto. Attached to this document is a copy of the form that you may use if you want to file a disclosure veto.

K. Adoption Search, Contact, and Reunion Services. When your child is at least 21 years old, your child, your child's other parent or siblings, or you may apply to the Director of the Social Services Administration of the Maryland Department of Human Services for adoption search, contact, and reunion services.

L. Rights Under the Indian Child Welfare Act. If you or your child are members of or are eligible for membership in an American Indian tribe, as defined by federal law, you have special legal rights under the Federal Indian Child Welfare Act (25 U.S.C. § 1901). You should not sign this consent form if you believe this may apply to you. You should tell the person requesting the consent or the court that you believe that your child's case should be handled under the Indian Child Welfare Act.

M. Authorization for Access to Medical and Mental Health Records. You may be asked to sign a separate form (authorization) to allow the adoptive parents and the guardian to get your child's medical and mental health records or your medical and mental health records. If you agree to allow access to this information, the records given to the adoptive parents will not include identifying information about you unless identifying information was previously exchanged by agreement.

N. Signature, Witness, and Copy. If you decide to complete and sign the consent form, you must have a witness present when you sign it. The witness must be someone 18 or older but may not be the child or the child's other parent. You must complete and sign the form with a pen and print or type in your name, address, and telephone number. The witness also must sign the form and print or type in the witness's name, address, and telephone number in the blanks on the last page.

You have the right to receive a copy of the signed consent form.

(Signature)

(Date)

You must attach a copy of these signed instructions to the signed consent form.

Check one of the following:

[ ] I already have spoken with a lawyer whose name and telephone number are __________, regarding this form and whether I should consent to the guardianship. I have read the instructions in front of this form, and I am ready to consent to the guardianship with the right to consent to adoption.

OR

[ ] I am at least 18 years old and am able to understand this document. I have read the instructions at the front of this form, and I do not want to speak with a lawyer before I consent to the guardianship with the right to consent to adoption.

D. Consent. Check one of the following statements:

[ ] After consulting or having the opportunity to consult with an attorney, I voluntarily and of my own free will consent to the ending (termination) of my parental rights and responsibilities with respect to my child and to the appointment of __________ [Department of Social Services or Montgomery County Department of Health and Human Services] to be the guardian of my child, with the right of the guardian to consent to the child's adoption or other planned permanent living arrangement.

OR

[ ] I voluntarily and of my own free will consent to the ending (termination) of my parental rights and to the appointment of __________ [Department of Social Services or Montgomery County Department of Health and Human Services], to be the guardian of my child on the condition that my child is adopted by __________.

Check one of the following:

[ ] I give up (waive) the right to any further notice of the guardianship case, any reviews after guardianship is granted, or when my child is adopted.

OR

[ ] I give up (waive) the right to any further notice of the guardianship case or any reviews after guardianship is granted, but I want to be notified when my child is adopted.

OR

[ ] I want to be notified about everything that happens in the guardianship case, all reviews after guardianship is granted, and when my child is adopted.

F. Right to Revoke Consent. If you sign the consent form and then change your mind and no longer want to consent, you have the right to revoke (cancel) the consent within 30 days after the date that it is filed in Juvenile Court. The only way that you can revoke this consent is by giving a signed written revocation statement with the name, sex, and date of birth of the child (if you know it) to:

Juvenile Clerk, Circuit Court for __________, at __________ (Address).

(Signature)

(Date)

(Printed Name)

Address

(City, State, Zip Code)

(Telephone Number)

(E-Mail Address)

(Witness Signature)

(Printed Name)

Address

(City, State, Zip Code)

(Telephone Number)

(E-Mail Address)

(Date)