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 10, 2002 • Albany New York  

 

BIRTH MOTHER FUTURE CONTACT STATEMENT

(1) I, Jane Smith, do hereby state that should my infant son, being placed for adoption this week, come to FAMILY FOCUS ADOPTION SERVICES in adulthood seeking information about me:

_____at this time I do allow FAMILY FOCUS ADOPTION SERVICES to release my name and address to my child.

_____at this time I do not allow FAMILY FOCUS ADOPTION SERVICES to release my name and address to my child.

I further confirm that I understand that I may contact FAMILY FOCUS ADOPTION SERVICES at any time in the future, in writing, to indicate that I have changed my mind, or to give an updated address.

In addition, if I choose to allow my child to get information about me, FAMILY FOCUS personnel can also give out the name, address, and telephone number of the following person, who will know where I am:

_______________________________________________

_______________________________________________

_______________________________________________

(2) For the years of my child's childhood, what I am requesting is a letter and pictures two times a year from the adopting family, sent through FAMILY FOCUS ADOPTION SERVICES. I understand that I must keep FAMILY FOCUS apprised of my current address at all times, in order for the letters and pictures to get to me.

 

_____________________

Signature of Birth Mother

 

_____________________

Witness

 

STATE OF NEW YORK) ss:

COUNTY OF NASSAU)

 

On this 26th day of March, 2002, 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