Form 67.13—A
	
Rule 67.13(1)
	
FORM OF CONSENT OF PARENT OR GUARDIAN UNDER SECTION 31(2)(a) OF THE ADOPTION AND CHILDREN (SCOTLAND) ACT 2007
	
*delete as appropriate	In the petition relating to the adoption of ………………………………………..

(insert the full name of the child as it is given in the birth certificate)
	
	*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] or [*share with the petitioner all the parental responsibilities and parental rights which I have at present in respect of the child]. I consent to the making of such an order.
	
	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 witness)
	
		[Full name of witness]
	
		Address