Government of Ontario: Ministry of Children, Community and Social Services

Acknowledgement of Adoption Placement

Note: Complete either Part A or Part B

Name(s) of prospective adoptive parent(s)

1. Last Name
1. First Name
1. Middle Initial

2. Last Name
2. First Name
2. Middle Initial

Last Name (Surname or initial of surname of child)
First Name (Given name(s) of child)
Date of birth (yyyy/mm/dd)
Birth registration no.

A. For child placed on parent’s consent

The above child has been placed with me/us on
Date of placement (yyyy/mm/dd)

I (We) understand that a parent of the child

has has not consented in writing to proposed adoption.

I (We) have had explained to me (us) and I (We) understand that each parent of this child has an absolute right to withdraw the consent given within 21 days following the date given, namely (state date(s) and consent(s), and add additional parents as necessary)

For one parent,

Date (yyyy/mm/dd)

For one parent,

Date (yyyy/mm/dd)

I (We) further understand that if the child’s parent(s) cancel their consent, the child will be removed from my (our) custody and care and that I (We) have no right to object to that removal.

I (We) further understand that if any of the child’s parents have not given their written consent to the proposed adoption, it will be necessary to obtain a court order dispensing with such consent.

B. For child who is a child in extended society care

The above child has been placed with me/us on
Date of placement (yyyy/mm/dd)

The child is a child in extended society care under the care of
Name of children’s aid society

Date of the Order placing the child in extended society care
Date (yyyy/mm/dd)

I (We) understand that all appeal periods have passed and there are no appeals pending.

1. Date (yyyy/mm/dd)
1. Signature of Witness

1. Signature of prospective adoptive parent

2. Date (yyyy/mm/dd)
2. Signature of Witness

2. Signature of prospective adoptive parent