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IN THE COURT OF COMMON PLEAS OF YORK (County of York)

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BROWSE COUNTY OF YORK (PA) FORMS

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Form A-2711 (Consent by parent of adoptee) Revision 5/2018
IN THE COURT OF COMMON PLEAS OF YORK COUNTY, PENNSYLVANIA
ORPHANS’ COURT DIVISION
IN RE: Adoption of : No. _____________________
:
------------------------------------------------------------------------------------- :
(Adoptee’s name exactly as it appears on birth certificate)
CONSENT BY PARENT OF ADOPTEE
TO THE HONORABLE, THE JUDGE OF SAID COURT:
The following is hereby represented to the Court:
1. The full names (including complete middle name), ages, marital status and relationship of each
parent to the above child are as follows:
Name Age Marital Status Relationship
_________________________ ____ ___________ __________
_________________________ ____ ___________ __________
(The identity of BOTH parents must be set forth above.)
2. This consent is executed more than 72 hours after the birth of said child (except that a putative
father) may execute a consent at any time after receiving notice of the expected or actual birth of
the child.
3. I hereby voluntarily and unconditionally consent to the adoption of said child.
4. I understand that by signing this consent I indicate my intent to permanently give up all rights to this
child.
5. I understand that such child will be placed for adoption.
6. I understand I may revoke this consent to permanently give up all rights to this child by placing the
revocation in writing and serving it upon the agency or adult to whom the child was relinquished.
7. If I am the BIRTH father or putative father of the child, I understand that this consent to an adoption
is irrevocable unless I revoke it within 30 days after either the birth or my execution of the consent,
whichever occurs later, by delivering a written revocation to:
__________________________________________________________________________________
(insert the name and address of the agency coordinating the adoption) OR
__________________________________________________________________________________
(insert the name and address of an attorney who represents the individual relinquishing parental
rights or prospective adoptive parent of the child) OR
__________________________________________________________________________________
(insert the Court of the county in which the voluntary relinquishment form was or will be filed).
(OVER THE CONTINUATION AND SIGNATURES)
Form A-2711 (Consent by parent of adoptee) Revision 5/2018
8. If I am the BIRTH mother of the child, I understand that this consent to an adoption is irrevocable
unless I revoke it within 30 days after executing it by delivering a written revocation to:
__________________________________________________________________________________
(insert the name and address of the agency coordinating the adoption) OR
__________________________________________________________________________________
(insert the name and address of an attorney who represents the individual relinquishing parental
rights or prospective adoptive parent of the child) OR
__________________________________________________________________________________
(insert the Court of the county in which the voluntary relinquishment form was or will be filed).
9. I have read and understand the above and I am signing it as a free and voluntary act.
Signed this _______day of _______________________, 20____, at _________o’clock _____.M.
At _______________________________________________________in the presence of the two
(place signed)
witnesses whose signatures appear below.
_________________________________ ____________________________________________
Print name of Consenting Parent Signature of Consenting Parent
WITNESSES
The undersigned two witnesses hereby certify that the above parent signed the above consent
in our presence on the above date.
Printed Name Address Relationship to Consenter
________________________________ ________________________ ________________________
________________________________ ________________________ ________________________
____________________________________________
Signature
____________________________________________
Signature
JOINDER BY PARENTS OF MINOR CONSENTER
The undersigned parents (or guardians) of the minor consenting parent who has not reached
the age of 18 years, herby join in such consent, and make all the representations to the Court set forth
in such consent.
Date:__________________
____________________________________________ _______________________________________
Print Name Signature
____________________________________________ ________________________________________
Print Name Signature
NOTICE
RE:
ADOPTIONS.
ANY
CONSENT
SIGNED
OUTSIDE OF
PA
MUST COMPLY WITH
THE
LAWS OF THE STATE
O
R
COUNTRY
WHERE IT WAS
SIGNED.
SEE 23 PA.C.S.A
§2711
(C)
.
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IN THE COURT OF COMMON PLEAS OF YORK (County of York)

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Completed 6 August 2020

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