The Art and Science of
Voluntary Surrender

Presented by Maris Blechner, Family Focus Adoption Services
NYS Citizens' Coalition for Children, Inc.
13th Annual Statewide Adoption Training Conference
Adoption 2002: Linking Promises to Possibilities
May 11, 2002 • Albany New York  

SURRENDERING BIRTH-PARENT'S CONFIRMATION OF SERVICES 

I, Jane Smith, residing at xxxxx xxx Street, Bayside, New York 11362, birth-mother of Baby Girl Smith, born on xxxxxx x, 2001, at Flushing Hospital Medical Center, Flushing, New York 11358, do hereby attest that:

(1 ) I have been advised and clearly understand that today I am permanently signing over my parental rights to FAMILY FOCUS ADOPTION SERVICES in order for my child Baby Girl Smith to be placed into an adoptive home, and that I am doing this of my own free will and without coercion;

(2) I have been advised and clearly understand that, as the surrender states, I have thirty days in which to change my mind about this surrender;

(3) I have been advised and clearly understand that I have the right to have an attorney present, and that I have the right to take these papers with me to show them to an attorney before I sign;

(4) Before signing any forms I have been advised and clearly understand that I have several options for the future of my child from which to choose;

(5) I have been given a copy of all of the forms that I have signed;

(6) I have been advised about the New York State Adoption Information Registry;

(7) I have been advised and clearly understand that I may contact a social worker at FAMILY FOCUS ADOPTION SERVICES at any time for personal counseling or if I have any questions.

 

Dated: February x, 2001                                                                         

 

_________________________

Signature of Birth Mother

 

_________________________

Witness

 

STATE OF NEW YORK) ss:

COUNTY OF QUEENS)

On this xth day of February, 2001, before me personally appeared Jane Smith; to me known and known to me to be the individual described in and who executed the foregoing instrument, and she duly acknowledged to me that she executed the same.

 

 

 _________________________                      

Notary Public

 

6/19/02