Form 67.39—A
	
Rule 67.39(1)
	
FORM OF CONSENT OF PARENT OR GUARDIAN UNDER SECTION 83(1)(c) [or 93(3)] OF THE ADOPTION AND CHILDREN (SCOTLAND) ACT 2007
	
	In the petition for permanence order in relation to the child
	
	(insert the full name of the child as it is given in the birth certificate)
	
	including provision granting authority for the child to be adopted

	
*delete as appropriate	*to which petition the court has assigned the serial number ……………………..
(insert serial number)

	
	I (name and address) …………………………………………………………….
	
	confirm that I am the mother/father/guardian of the child. I fully understand that the effect of the making of an adoption order in respect of the child will be to [*extinguish all the parental responsibilities and parental rights which I have at present in respect of the child]. I consent generally and unconditionally to the making of an adoption order in relation to the child. I have signed this consent at (place of signing) on the ………………. day of …………………Two thousand and ………………..

	(signature)

This consent was signed in the presence of:-
	
	(signature of reporting officer)

[Full name of reporting officer]

Address