Md. R. Juv. Causes, Form 11-309
A consent by a parent to guardianship shall be substantially in the following form:
CONSENT BY PARENT TO GUARDIANSHIP WITH THE RIGHT TO
CONSENT TO ADOPTION OF [NAME OF CHILD] BY [NAME OF
LOCAL DEPARTMENT/GUARDIAN]
INSTRUCTIONS
The attached written consent form is an important legal document. You must read all of these instructions BEFORE you decide whether to sign the consent form. If you do not understand the instructions or the consent form, you should not sign it. If you are under 18 years old or if you have a disability that makes it difficult for you to understand, do not sign the consent form unless you have a lawyer.
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:
1. Except as otherwise specified in this consent, terminates all of your parental rights to your child;
2. Makes the local department of social services the legal guardian of the child;
3. Grants to the local department of social services the authority to consent to the adoption or other planned permanent living arrangement of the child without the need of any further consent by you; and
4. Also grants to the local department of social services the authority to take other actions regarding the child specified in § 5-325(b) of the Courts and Judicial Proceedings Article of the Maryland Code.
B. Right to Speak with a Lawyer
1. You have the right to speak with a lawyer before you decide whether to sign the consent.
2. If a lawyer has been appointed for you in a CINA case, speak with that lawyer before you decide whether to sign this consent. If a lawyer has not been appointed for you and you are unable to afford a lawyer, you may be eligible for a lawyer free of charge through the Office of the Public Defender. You should contact the Office of the Public Defender, and ask for a lawyer to represent you in a D.S.S. (Department of Social Services) guardianship case. The Public Defender's telephone number is ___________________. The e-mail address is.
3. If you are under 18 years old or have a disability that makes it difficult for you to understand this document, you must have a lawyer review the form with you before you can consent to the guardianship. You should contact the Office of the Public Defender or let the Juvenile Court know that you need to have a lawyer appointed for you.
4. Even if you do not have the right to have the court appoint a lawyer for you or to be represented through the Office of the Public Defender, you have the right to speak with a lawyer you choose before you decide whether to consent.
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:
1. You can consent to the guardianship and the adoption of your child by any family approved by the local [Department of Social Services or Montgomery County Department of Health and Human Services]; or
2. You can consent to the guardianship only if the child is adopted into a specific family. This is called a "conditional consent." If you sign a conditional consent, and the family whose name is on the consent cannot adopt the child, your consent will no longer be valid. The court will try to locate you to find out if you want to sign a new consent. If you do not sign a new consent, the court can have a trial to decide whether your parental rights should be ended (terminated) and whether guardianship with the right to consent to adoption should be granted, even without your consent.
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.
G. Right to Revoke Consent
1. 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).
2. The written and signed revocation statement must be sent to the court, not to your social worker or lawyer. You may deliver your written revocation of consent in person or by mail.
If it is not received by the Juvenile Clerk's office within 30 days after the date the consent form was filed in court, it will be too late, and you will not be able to withdraw the consent or stop the guardianship from being granted.
H. Further Notice of Guardianship and Adoption Proceedings
1. A petition for guardianship with the right to consent to adoption has been or will be filed in the Juvenile Court for ________________________County/Baltimore City. If you sign the consent form, it will also be filed in the Juvenile Court.
2. You have the right to be notified when the petition is filed, about any hearings before or after a guardianship is granted, and if a guardianship is granted, if and when the child is adopted. Any notices will be sent to the address given by you on the consent form, unless you write to the Juvenile Clerk at _________________________(court's address) and give the clerk your new address. You may waive (give up) your right to notice if you wish to do so. Even if you give up your right to notice, someone from the court may contact you if further information is needed. Receiving notice of a hearing does not give you the right to attend the hearing. If you wish to be present at a hearing, you may contact the court and request permission to attend.
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 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.
STOP HERE IF YOU DID NOT UNDERSTAND SOMETHING YOU HAVE READ OR IF YOU WANT TO SPEAK WITH A LAWYER BEFORE YOU DECIDE IF YOU WANT TO SIGN THE CONSENT FORM.
If you wish to sign the consent form, you must first sign here to verify that you read these instructions and understand them:
_________________________ __________________________________
(Signature) (Date)
You must attach a copy of these signed instructions to the signed consent form.
CONSENT TO GUARDIANSHIP WITH THE RIGHT TO CONSENT TO ADOPTION OR OTHER PLANNED PERMANENT LIVING ARRANGEMENT OF
______________________TO _______________________
Use a pen to fill out this form. You must complete each section.
A. Language of Form
1. The instructions and this consent form are in __________ (language), which is a language I can read and understand.
2. If the form is in a language other than English, attached to it is an affidavit in English of the person who translated the document from English attesting that the translation is accurate and listing the translator's qualifications.
B. Identifying Information
1. Name
My full name is
_____________________.
2. Age
My date of birth is.
_____________________.
3. Child's Birth Information
The child who is the subject of this consent was born on _______________________(date) at ___________________________ (name of hospital or address of birthplace) in _________________ (city, state, and county, and country of birth)
4. Status as Parent
(a) I am
[ ] the mother of the child;
[ ] the father of the child;
[ ] alleged to be the father of the child; or
[ ] found by a court to be the "de facto" parent of the child.
(b) If I checked "alleged to be the father of the child" or "found by a court to be the 'de facto' parent of the child" (Check all that apply):
(1) [ ] I was married to the mother of the child at the time of conception of the child.
(2) [ ] I was married to the mother of the child at the time the child was born.
(3) [ ] I was the registered domestic partner of the parent of the child at the time of conception of the child.
(4) [ ] I was the registered domestic partner of the parent of the child at the time the child was born.
(5) [ ] Repealed
(6) [ ] Repealed
(7) [ ] I was named as the father on the child's birth certificate.
(8) [ ] The child's mother named me as the child's father.
(9) [ ] I have been adjudicated by a court to be the child's father.
(10) [ ] I have acknowledged myself orally or in writing to be the child's father.
(11) On the basis of genetic testing, I [ ] have been
[ ] have not been indicated to be the child's biological father.
(12) [ ] I do not know if I am the father of the child.
(13) [ ] I deny that I am the father of the child.
C. Advice of Counsel; Right to Speak with a Lawyer
I WANT TO COMPLETE THIS CONSENT FORM BECAUSE:
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. Rights Under the Indian Child Welfare Act
Check the following statement if it applies to you:
[ ] I am not a member of an Indian tribe or eligible to become a member of an Indian tribe.
OR
[ ] I am a member of an Indian tribe or believe I may be enrolled in a tribe. The name of the tribe is____________, located in__________________.
E. 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 ________________________________.
F. Further Notice
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.
G. 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 revoction statement with the name, sex, and date of birth of the child (if you know it) to:
Juvenile Clerk, Circuit Court for _____________________, at ______________________________________________________(Address).
H. Effect of this Consent
I UNDERSTAND THAT IF I SIGN THIS CONSENT FORM AND GUARDIANSHIP IS GRANTED, I WILL BE GIVING UP ALL RIGHTS AND RESPONSIBILITIES RELATING TO THE CHILD, EXCEPT THOSE RIGHTS THAT I HAVE KEPT UNDER ANY WRITTEN POST-ADOPTION AGREEMENT.
_____________________ ______________________
(Signature)
_____________________
(Date)
_____________________
(Printed Name)
_____________________
Address
_____________________
(City, State, Zip Code)
_____________________
(Telephone Number)
_____________________
(E-Mail Address)
_____________________ ______________________
(Witness Signature) (Date)
_____________________
(Printed Name)
_____________________
Address
_____________________
(City, State, Zip Code)
_____________________
(Telephone Number)
_____________________
(E-Mail Address)
I. Oath and Signature
Md. R. Juv. Causes, Form 11-309