Consent to adoption. 

[Title of court]

In the Matter of the Adoption of _________ by _________

We, _________ and _________, father and mother [or as the case may be]  of _________, a minor child _________ years of age, hereby consent to the adoption of the child by _________, as sought in the attached petition of _________, and hereby waive all right to the custody and control of the child.

Dated this _________ day of _________, _________[date].

[Signatures]

[Acknowledgment if required by statute]