Victorian Consolidated Regulations Victorian Consolidated RegulationsFORM 1
APPLICATION UNDER SECTION 13(1) OF THE ADOPTION ACT 1984 FOR APPROVAL AS FIT AND PROPER PERSON TO ADOPT A CHILD
To: *The Secretary to the Department of Justice and Community Safety/*the principal officer of [ insert name of approved agency ]
In respect of each applicant
Full name of applicant:
Previous surnames, if any:
Residential address:
Postal address:
Telephone number (home)
(mobile)
(work)
Email address:
Gender:
Age and date of birth:
State or country of birth:
Nationality:
If naturalised, date of citizenship/naturalisation:
Cultural identity:
Aboriginal or Torres Strait Islander (include country):
Religion:
Relationship status: [ married, registered domestic relationship, domestic relationship, divorced, separated, widowed, single ] [ You may be required to supply evidence .]
Date and place of marriage or registered domestic relationship: [ country, state, town or suburb ]
If currently in a domestic relationship, date of commencement of that relationship:
Previous marriages or domestic relationships: [ insert names and dates ]
If divorced, date and country or state of divorce order:
If applicable, date of death of husband, wife or partner:
Are you willing to encourage access to a child's natural parents and family?
Are you willing to exchange information about the child with the natural parents and family of the child?
Are you willing to participate in the formation of an adoption plan for the child?
Health of each applicant
Describe the state of your health (including emotional, physical and mental health) :
Give the name, address and telephone number of—
your current medical practitioner or a medical practitioner who has recently treated you (including any specialist) who may be contacted for a medical report about you:
a mental health professional such as a psychologist who may be contacted for a psychological report about you:
Household and family members of each applicant
Give the name and date of birth of each child currently or previously in your care:
State the relationship of each child to the applicant: [ for example, *by birth/*placement under an adoption or other court order (give details)/*foster care or kinship care arrangement (give details) ]
Give the names and contact details of adult children, if any, of the applicant who may be contacted by the Secretary or the principal officer of an approved agency for further information:
Capacity of the applicant to provide stable, secure and beneficial emotional and physical environment for child
Do you own or rent your residence?
Describe the physical environment in which you live: [ for example, a house or apartment (give details) ]
Do you have a separate room for a child placed with you for adoption?
Have you previously had the care of a child?
If you have previously had the care of a child, describe how you met the child's emotional, social and health needs and any specific issues encountered:
If you have not previously had the care of a child, describe how you would meet a child's emotional, social and health needs:
Educational level achieved by each applicant:
Professional, academic or training qualifications of each applicant:
Current occupation of each applicant: [ include household duties or unemployed, if applicable ]
Name and address of current employer of each applicant:
Financial circumstances
Provide the following information in respect of each applicant:
Annual income including—
Salary or wages
Net income from business
Dividends and interest
Rental income
Payments from Centrelink (indicating type of benefit)
Spousal maintenance and child support from previous marriage or relationship
Other income (specify)
[ Specify if joint income ]
Total annual income
Annual expenses including—
Income tax
Health insurance
Rent
Rates and taxes
Mortgage payments (residential, investment and business properties)
Food and household expenses
Electricity, gas, fuel
Telephone
Clothing
Child care and education
Entertainment
Fares
Car maintenance and registration
Hire purchase/credit payments
Maintenance and child support from previous marriage or relationship
Education and professional membership fees
Personal loans
Travel
Other expenses (specify)
[ Specify if joint expenditure ]
Total annual expenditure
Assets (current values)
Real estate: Capital improved value of residence
Capital improved value of investment property
Shares and debentures [ state holdings and current value ]
Savings and cash
Life insurance/income protection insurance [ state whether insurance held ]
Motor vehicles
Other assets
Liabilities (not otherwise stated under "Expenses")
Mortgage amounts owing on residence, investment property, business property
Personal loans (including credit cards)
Other liabilities
Criminal history
Have you been convicted or found guilty by a court (whether in Victoria or elsewhere) of any offence?
Referees
Give the name, address, telephone number and relationship to the applicant of 4 persons who are willing to act as referees for the applicant or applicants. One referee should be from each applicant's family and the remaining two referees should not be relatives but should know the applicant and the applicant's family well.
Signature of each applicant:
Signature of witness:
Full name and address of witness:
Date of signing:
*delete if inapplicable
If any question does not apply to you write N.A. in the space provided. Attach
additional pages if required. Information about religion, race or ethnic
background is relevant as the wishes of a natural parent as to placement of
their child must be considered.
FORM 2
WISHES OF NATURAL PARENT WITH RESPECT TO RELIGION, RACE OR ETHNIC BACKGROUND OF ADOPTIVE PARENTS
Full name, address and date of birth of the natural parent of the child: [ insert details ]
Name, date of birth and place of birth of the child: [ insert details ]
The parent *does/*does not wish to express a preference about the religion, race or ethnic background of any proposed adoptive parents of the child.
If the parent wishes to express a preference, a statement of the parent's wishes with respect to—
(a) religion; or
(b) race; or
(c) ethnic background—
of the adoptive parents being considered for the placement of the child:
[ insert statement of wishes expressed by parent ]
The parent understands that, although the parent's wishes will be considered carefully, it may not be possible to place the parent's child with people who meet all of the parent's wishes.
Signature of the parent:
Signature of an approved counsellor:
Date and place of signing:
*delete if inapplicable
FORM 3
WISHES OF NATURAL PARENT WITH RESPECT TO ACCESS TO CHILD AND INFORMATION ABOUT CHILD
Full name, address and date of birth of the natural parent of the child: [ insert details ]
Name, date of birth and place of birth of the child: [ insert details ]
Date on which consent to adoption was given or dispensed with: [ insert date ]
The natural parent understands that—
(a) the Secretary or the principal officer of an approved agency must consider both the natural parent's wishes and the welfare and interests of the natural parent's child before placing the child for adoption; and
(b) it may not be possible to find a placement for the natural parent's child that meets all the natural parent's wishes and that the Secretary or the principal officer of an approved agency may place the child in a placement that does not fit the natural parent's wishes if this is in the child's interests; and
(c) if the adoptive parents and the natural parent agree, arrangements about information or access to the child may be included as conditions of an adoption order; and
(d) if conditions are included in an adoption order, an adoptive parent of the adopted child, a parent who gave consent to the adoption of the child, the adopted child or a person on behalf of the adopted child may later apply to the Court to vary or revoke the conditions; and
(e) if conditions are not included in an adoption order, an adoptive parent of the adopted child, a parent who gave consent to the adoption of the child, the adopted child or a person on behalf of the adopted child may later apply to the Court to vary the adoption order to include one or more conditions; and
(f) an order to include, vary or revoke a condition, the effect of which is to grant a person a right of access, or greater rights of access, to the adopted child, cannot be made unless—
(i) the adoptive parent or parents agree; and
(ii) the Court is satisfied that, as far as practicable, the wishes of the adopted child have been ascertained and due consideration is given to those wishes, having regard to the age and understanding of the child.
Information about child
The natural parent *does/*does not wish to be contacted and advised if no placement is available to meet the natural parent's wishes.
The natural parent *does/*does not wish to be given information about the child.
*If the natural parent does wish to be given information about the child, the frequency with which the parent wishes the information to be given is: [ insert frequency ]
The natural parent *does/*does not wish to have the natural parent's wishes for information about the child included as a condition in an adoption order.
Access to child
The natural parent *does/*does not wish to have access to the child.
*If the natural parent does wish to have access to the child, the frequency with which the parent wishes to have access is: [ insert frequency ]
The natural parent *does/*does not wish to allow relatives to have access to the child.
*If the natural parent does wish to allow relatives to have access to the child, the name and address of the relative or relatives to have access, relationship to the child, and the frequency of access are: [ insert details ]
The natural parent *does/*does not wish to have the natural parent's wishes for access to the child included as a condition in an adoption order.
Signature of the parent:
Signature of an approved counsellor:
Date and place of signing:
*delete if inapplicable
FORM 4
Regulations 9 and 10
APPLICATION FOR APPROVAL OR RENEWAL OF APPROVAL OF ADOPTION AGENCY
TO: The Secretary to the Department of Justice and Community Safety
Name of welfare organization:
Address of welfare organization:
applies for the *approval/*renewal of approval of the welfare organization as an approved agency.
Person nominated as principal officer of the welfare organization for the purposes of the Act:
*Person nominated as deputy principal officer of the welfare organization for the purposes of the Act:
The governing body of the welfare organization is:
The membership of the governing body is:
The interests of members in the governing body are:
A copy of the *rules/*constitution/*memorandum or *articles of incorporation of the welfare organization is attached.
*A copy of each instrument evidencing the trusts related to the welfare organization is attached.
The proposed method of financing the approved agency is: [ include a financial statement and budget estimate ]
Reasons for the application for approval/renewal of approval as an approved agency:
The experience of the welfare organization in adoption or related family welfare services is as follows:
The links of the welfare organization with other child and family welfare services are as follows: [ include arrangements for the care of a child before adoptive placement and after a child is removed from an adoptive placement ]
If adoption of children from overseas countries is proposed, the links that the welfare organization has established or proposes to establish with organisations or persons in those countries are as follows:
The location of the proposed approved agency is:
The populations and geographical area of Victoria that the approved agency would serve are:
The activities that the welfare organization proposes to undertake in relation to arranging adoptions are:
The accommodation to be used for the proposed approved agency is: [ include rooms suitable for the conduct of assessments, interviews, training and support for adoption arrangements ]
The number, experience, qualifications and duties of staff engaged or proposed to be engaged by the proposed approved agency are:
The training of staff is or is proposed to be as follows:
The method of keeping records in relation to persons seeking to adopt children, natural parents of children placed for adoption and children placed for adoption undertaken or proposed to be undertaken by the proposed approved agency is as follows:
The procedures for internal review and evaluation of the activities of the proposed approved agency are as follows:
The constitution of the proposed approved agency's placement and assessment committee:
*delete if inapplicable
FORM 5
CONSENT TO ADOPTION
Full name of the person giving consent:
Address of the person giving consent:
Date and place of birth of the person giving consent:
Full name of the child:
Date of birth of the child:
Place of birth of the child:
*General consent
Relationship of the child to the person giving consent:
I [ full name of person giving consent ] consent to the adoption of the child.
In giving consent, I understand that when the Court makes an adoption order—
(a) I will lose my rights as a parent of the child; and
(b) those rights will be transferred to the person or persons who adopt the child; and
(c) the child will be treated in law as the child of the person or persons who adopt the child.
I understand that an adoption agency will make any arrangements needed before an adoption order is made.
I authorise *the Secretary to the Department of Justice and Community Safety/*the principal officer of an approved agency [ insert name of adoption agency ] to make these arrangements.
I understand that, when all consents that are needed have been given, the *Secretary/*the principal officer of an approved agency will become the guardian of the child.
*Where the child is proposed to be adopted by the spouse or domestic partner of the person giving consent
Full name of the spouse or domestic partner:
I consent to the Court making an adoption order for the child in favour of my spouse or domestic partner.
I consent on the understanding that my rights as a parent will not be altered in any way by an adoption order in favour of my spouse or domestic partner.
I understand that an adoption order gives me and my spouse or domestic partner the same rights as parents of the child that both would have if they were married when the child was born.
I understand that the Court may consider that a parenting order is more appropriate than an adoption order and that, in these circumstances, the Court will not make an adoption order.
I authorise *the Secretary to the Department of Justice and Community Safety/*the principal officer of an approved agency [ insert name of adoption agency ] to conduct negotiations, or make arrangements or prepare any reports needed before an adoption order is made.
*Where the child is proposed to be adopted by—
• the spouse or domestic partner of the child's other parent;
• a relative of the child;
• the spouse or domestic partner of a relative of the child;
Full name of the person proposing to adopt the child:
Address of the person proposing to adopt the child:
Relationship of the child to the person proposing to adopt the child:
I consent to the adoption of the child by: [ insert name of person proposing to adopt the child ]
In giving consent, I understand that when the Court makes an adoption order—
(a) I will lose my rights as a parent of the child; and
(b) those rights will be transferred to the person or persons who adopt the child; and
(c) the child will be treated in law as the child of the person or persons who adopt the child.
I understand that the Court may consider that a parenting order is more appropriate than an adoption order and that, in these circumstances, the Court will not make an adoption order.
I authorise *the Secretary to the Department of Justice and Community Safety/*the principal officer of an approved agency [ insert name of adoption agency ] to conduct negotiations, or make arrangements or prepare any reports needed before an adoption order is made.
*Where parent wishes child to be adopted within the Aboriginal community
*I am of Aboriginal descent and I regard myself as Aboriginal and am accepted as Aboriginal by an Aboriginal community.
*I am not Aboriginal but believe that the other parent of the child is of Aboriginal descent, regards themselves as Aboriginal and is accepted as Aboriginal by an Aboriginal community.
It is my wish that the child be adopted within the Aboriginal community.
I understand that the Secretary or the principal officer of an approved agency is required to contact me if—
(a) my conditions for access cannot be met; or
(b) no suitable adoptive parent or parents are available within the Aboriginal community.
If the Secretary or the principal officer of an approved agency does contact me, I understand that I may within 28 days revoke my consent to the adoption or vary my conditions for access.
I understand that the Secretary or the principal officer of an approved agency is not required to contact me if the only suitable adoptive parents are not Aboriginal but are approved as suitable by an Aboriginal agency.
I understand that any conditions relating to access by me, relatives of the child or members of the Aboriginal community or the connection of the child to the Aboriginal community will be included as conditions of an adoption order as long as suitable adoptive parents can be found who accept those conditions.
The conditions relating to access to which this consent is subject are:
[ Specify conditions and in particular state—
(a) whether it is a condition of consent that the person giving consent has access to the child and, if so, when the person wishes access to occur; or
(b) whether it is a condition of consent that relatives of the child have access to the child and, if so, the full name, address and relationship of each relative to the child; or
(c) whether it is a condition of consent that members of an Aboriginal community have access to the child from time to time. ]
Signature of the person giving consent:
Date and place of signing:
Signed in the presence of:
[ signature of first witness ]
[ signature of second witness ]
*delete if inapplicable
FORM 6
STATEMENT OF WITNESSES WHEN CONSENT IS GIVEN TO AN ADOPTION WITHIN AUSTRALIA
FIRST WITNESS
Full name of the person giving consent:
Address of the person giving consent:
Date and place of birth of the person giving consent:
Full name of the child:
Date of birth of the child:
Place of birth of the child:
Full name of first witness:
Address of first witness:
Qualification of first witness:
The following statement is to be signed by a person who is—
(a) a prescribed official of a court referred to in regulation 15(1); or
(b) a person referred to in section 34(2)(b) or (c) of the Adoption Act 1984 .
I, [ insert full name of first witness ] was present when [ insert name of the person giving consent ] signed the form of consent.
I am signing this statement in the presence of [ insert name of person giving consent ] and [ insert name of second witness ].
Signature of first witness:
Date and place of signing:
SECOND WITNESS
Full name of the person giving consent:
Address of the person giving consent:
Date and place of birth of the person giving consent:
Full name of the child:
Date of birth of the child:
Place of birth of the child:
Full name of second witness:
Address of second witness:
Qualification of second witness:
The following statement is to be signed by a person who is approved for the purpose by the Secretary or the principal officer of an approved agency under section 34(1)(a)(ii) of the Adoption Act 1984 :
I, [ insert full name of second witness ] was present when [ insert name of person giving consent ] signed the form of consent.
I am signing this statement in the presence of [ insert name of person giving consent ] and [ insert name of first witness ].
Signature of second witness:
Date and place of signing:
FORM 7
STATEMENT OF WITNESSES IN WHOSE PRESENCE THE FORM OF CONSENT IS SIGNED WHEN CONSENT IS GIVEN TO AN ADOPTION IN A COUNTRY OUTSIDE AUSTRALIA
FIRST WITNESS
Full name of the person giving consent:
Address of the person giving consent:
Date and place of birth of the person giving consent:
Full name of the child:
Date of birth of the child:
Place of birth of the child:
Full name of first witness:
Address of first witness:
Qualification of first witness:
The following statements are to be signed by a person referred to in section 34(3)(a) of the Adoption Act 1984 :
I, [ insert full name of first witness ] was present when [ insert name of person giving consent ] signed the form of consent.
*Not less than 7 days before consent is given/*Less than 7 days but not less than 24 hours before consent is given, I gave [ insert name of person giving consent ] information about—
(a) the effect of an adoption order under the Adoption Act 1984 ; and
(b) the alternatives to adoption available in Victoria.
I am signing this statement in the presence of [ insert name of person giving consent ] and [ insert name of second witness ].
Signature of first witness:
Date and place of signing:
*delete if inapplicable
SECOND WITNESS
Full name of the person giving consent:
Address of the person giving consent:
Date and place of birth of the person giving consent:
Full name of the child:
Date of birth of the child:
Place of birth of the child:
Full name of second witness:
Address of second witness:
Qualification of second witness:
The following statement is to be signed by a person referred to in section 34(3)(a) of the Adoption Act 1984 :
I, [ insert full name of second witness ] was present when [ insert name of person giving consent ] signed the form of consent.
*Not less than 7 days before consent is given/*Less than 7 days but not less than 24 hours before consent is given, I gave [ insert name of person giving consent ] information about—
(a) the effect of an adoption order under the Adoption Act 1984 ; and
(b) the alternatives to adoption available in Victoria.
I am signing this statement in the presence of [ insert name of person giving consent ] and [ insert name of first witness ].
Signature of second witness:
Date and place of signing:
*delete if inapplicable
FORM 8
NOTICE TO PARENT CONSIDERING PLACING A CHILD FOR ADOPTION
When you are thinking about adoption for your child there are a number of different arrangements you can consider for raising your child. One of these arrangements may be best suited to you and your child.
These arrangements include—
• raising the child yourself using the supports and financial benefits available in your community.
• temporary care by another family until you have set up living arrangements, income and other supports.
• permanent care of your child by another person who may have a legal order such as a parenting order. These orders involve the transfer of your legal responsibilities as a parent.
• adoption of your child by another person under an adoption order. An adoption order involves the transfer of all of your legal responsibilities as a parent.
When an adoption is finalised the Court makes an adoption order.
This causes major legal changes affecting your relationship with
your
child.
Transfer of rights and responsibilities
Once an adoption order is made the child is treated in law in every way as the child of the parents who adopt the child. Your rights and responsibilities as a parent are given to the adoptive parent. An adoption order is permanent unless there are exceptional circumstances.
Names of the child
After adoption the child may have new names. When an adoption order is made the Court approves the names of the child specified in the adoption application. The surname is usually the surname of the parents applying to adopt.
They also select given names which may be new names or names by which the child is known.
New birth certificate
After adoption your child receives a new birth certificate which names the adoptive parents as the parents of your child and does not include your name.
Inheritance
After adoption your child is entitled to inherit from the adoptive parents as if the child was born to them.
Your child may only inherit from you or your relatives if named in your will or the will of a relative.
Rights of natural parent
The law allows natural parents to have some rights after an adoption order is made.
It entitles you to some information about your child after an adoption order is made.
You may be entitled to have access to your child if this has been included in the adoption order, or if other arrangements have been agreed to by you and the adoptive parents.
When an adoption order is granted to a step-parent who is married to, or in a domestic relationship with, the parent still caring for the child, the law regards both of these parents as the child's parents. The parent still caring for the child in this case does not lose any of their rights as a parent.
If you are the other parent of the child (that is the parent who is no longer caring for the adopted child) you are no longer treated in law as the child's parent. All of the usual effects of an adoption order would apply to you once an adoption order is made.
At any time before or after an adoption order is made you may apply, subject to and in accordance with the Births, Deaths and Marriages Registration Act 1996 to the Registrar of Births, Deaths and Marriages for a certified copy of, or extract from, the entry in the Register of Births relating to the child.
To obtain a copy of your child's original birth certificate you should apply either in writing or in person to—
The Registrar of Births, Deaths and Marriages,
Ground Floor, 595 Collins
Street
Melbourne 3000.
There are a number of organisations that provide family support services.
The names and addresses of organisations identified by your counsellor
are:
[ insert name and addresses of organisations ]
YOUR COUNSELLOR WILL ALSO DISCUSS WITH YOU THE FINANCIAL OR OTHER SUPPORT THAT MAY BE AVAILABLE TO YOU WHETHER OR NOT THE CHILD IS PLACED FOR ADOPTION.
FORM 9
CERTIFICATE UNDER SECTION 35(3) OF THE ADOPTION ACT 1984
Full name of the person giving consent:
Address of the person giving consent:
Date and place of birth of the person giving consent:
Full name of the child:
Date of birth of the child:
Place of birth of the child:
Full name of person completing the certificate:
Address of person completing the certificate:
I, [ insert full name of person signing certificate ], *Secretary/*principal officer of [ insert name of approved agency ] certify that the following requirements under section 35(1) of the Adoption Act 1984 have been complied with before consent was given by [ insert name of person giving consent ] to the adoption of [ insert name of child ]:
(a) Counselling
On [ insert date or dates that counselling was given ] [ insert name of person giving consent ] received counselling from [ insert name of approved counsellor ] of [ insert address of approved counsellor ].
I approved [ insert name of approved counsellor ] under section 35(1)(a) of the Adoption Act 1984 .
(b) Information about the effects of adoption
*Not less than 7 days before consent is given/*Less than 7 days but not less than 24 hours before consent is given, [ insert name of approved counsellor ] gave [ insert name of person giving consent ] information about the effect of an adoption order, the alternatives to adoption and the name and addresses of organisations that provide family support services on [ insert date information was given ].
(c) Right to apply for birth certificate
[ Insert name of person giving consent ] was given notice in writing that, [ insert name of person giving consent ] may, at any time make application subject to and in accordance with the Births, Deaths and Marriages Registration Act 1996 for a certified copy of the entry in the Register of Births relating to [ insert name of child ].
Signature of *Secretary/*the principal officer of an approved agency:
Date of signing:
*delete if inapplicable
FORM 10
CONSENT BY GUARDIAN OR DELEGATE OF GUARDIAN TO ADOPTION OF NON-CITIZEN CHILD
Full name of the person giving consent:
Address of the person giving consent:
Date and place of birth of the person giving consent:
Full name of the child:
Date of birth of the child:
Place of birth of the child:
Address of the child before travelling to Australia:
I, [ insert full name of guardian or delegate of guardian ] am a *guardian/*the delegate of a guardian of [ insert name of child ] under the Immigration (Guardianship of Children) Act 1946 of the Commonwealth.
I consent to the adoption of the child.
I believe on reasonable grounds that—
*(a) each of the parents of the child has given consent, in accordance with the law of the place of residence of that parent or of the child immediately before the child began the journey to Australia, to the adoption of the child and has not revoked that consent; or
*(b) each of the parents of the child is dead; or
*(c) each of the parents of the child cannot be found after reasonable inquiry; or
*(d) circumstances exist by reason of which the consent of a parent could be dispensed with if the consent of the parent were required under the Adoption Act 1984 [ insert details of the circumstances (including sources of information and documentation and by whom sources were verified) ].
Signature of the guardian or delegate of the guardian:
Date and place of signing:
*delete if inapplicable
FORM 11
NOTICE TO PARENT OF ABORIGINAL CHILD OF INABILITY TO FIND A PERSON OR PERSONS SUITABLE TO ADOPT CHILD
Name of parent:
Address of parent:
Name of the child:
Date consent was given:
Name and title of the person giving the notice:
*Name, address and telephone number of approved agency:
I am unable to find a person or persons suitable to adopt [ insert name of child ] subject to the following condition under section 37(1) of the Adoption Act 1984 : [ insert details of condition ]
In response to this notice, you may:
(a) change this condition; or
(b) revoke your consent to the adoption; or
(c) take no action at all.
Signature of *Secretary/*the principal officer of an approved agency:
Date:
*delete if inapplicable
FORM 12
NOTICE VARYING A CONDITION OF CONSENT TO ADOPTION OF AN ABORIGINAL CHILD
To: the Registrar of the County Court
Name of parent:
Address of parent:
Date of birth of parent:
Name of the child:
Name and title of the person giving the notice:
*Name, address and telephone number of approved agency:
I have been advised by the *Secretary/*principal officer of [ insert name of approved agency ] that the *Secretary/*principal officer was unable to find an adoptive parent or adoptive parents suitable to adopt my child subject to the following condition under section 37(1) of the Adoption Act 1984 : [ insert details of condition ]
I wish to vary this condition as follows: [ insert details of variation ]
Signature of parent:
Date of signing:
Signature of witness:
Signature of approved counsellor:
*delete if inapplicable
FORM 13
NOTICE TO PARENT THAT AN ADOPTIVE PLACEMENT CANNOT BE FOUND FOR A CHILD
Name and address of the person who has given consent to adoption:
Date consent was given:
Name of the child:
Name and title of the person giving the notice:
*Name, address and telephone number of approved agency:
I am of the opinion that it is no longer possible to place [ insert name of child ] with [ insert name of adoptive parent/names of adoptive parents ].
You may wish to consider—
(a) the arrangements for the long-term care of the child; and
(b) the legal guardianship of the child; and
(c) whether you wish to revoke consent to the adoption.
In response to this notice you may—
(a) within 56 days after the date of this notice, revoke your consent to the adoption; or
(b) do nothing and your consent to the adoption will be revoked 140 days after the date of this notice.
Signature of *Secretary/*the principal officer of an approved agency:
Date of notice:
*delete if inapplicable
FORM 14
NOTICE REVOKING CONSENT TO ADOPTION
To: The Registrar of the County Court
250 William Street
Melbourne
VIC 3000
*Name and address of approved agency arranging the adoption:
*Name of officer of the Department of Justice and Community Safety arranging the adoption:
Name and address of the person revoking consent:
Date of birth of the person revoking consent:
Date consent was given:
Name of the child:
I, [ insert name of person revoking consent ] revoke my consent to the adoption of [ insert name of child ].
Signature of person revoking consent:
Date of notice:
Signature of witness:
*delete if inapplicable
FORM 15
EXTENSION OF PERIOD FOR REVOKING CONSENT TO ADOPTION
*Name and address of approved agency arranging the adoption:
*Name of officer of the Department of Justice and Community Safety arranging the adoption:
Name and address of the person extending the period for revoking consent:
Date of birth of the person extending the period for revoking consent:
Name of the child:
Date consent was given:
Under section 41(1)(a) of the Adoption Act 1984 , I [ insert name of person extending the period for revoking consent ] declare that the period of 28 days by which I may revoke consent is extended by [ insert period of time of extension that is not more than 14 days ].
Signature of the person extending the period for revoking consent:
Date of notice:
Signature of a witness:
*delete if inapplicable
FORM 16
RECORD OF WISHES OF NATURAL PARENT WITH RESPECT TO NOTIFICATION OF EVENTS
Name of person giving consent:
Date of birth of person giving consent:
Address of person giving consent:
Name and date of birth of the child:
For the purposes of section 44(2) of the Adoption Act 1984 , I [ insert name of person giving consent ] do not wish to be given notice of the following events:
*(a) the end of the period of time by which I may revoke my consent to the adoption;
*(b) the placement of my child with a proposed adoptive parent or adoptive parents;
*(c) the termination of my child's placement with a proposed adoptive parent or adoptive parents;
*(d) the Secretary or the principal officer of an approved agency is no longer the guardian of my child;
*(e) my child dies before an adoption order is made;
*(f) the Court makes an adoption order in relation to my child.
Signature of person giving consent:
Signature of an approved counsellor:
Date and place of signing:
*delete if inapplicable
FORM 17
MEMORANDUM OF AN ADOPTION ORDER
Details of the child
Registered birth given name or names and family name of the child:
Date and place of birth of the child:
If the place of birth of the child is not known, record the place where the child was first located.
Sex of the child:
Given name or names and family name of the child under the adoption
order:
* Details of each parent, in the case of adoption by 2 adoptive parents
Given name or names and family name (including maiden name, if applicable) of each adoptive parent:
Each adoptive parent's place of birth and age at the date of birth of the
child:
Each adoptive parent's usual occupation:
Each adoptive parent's place of residence:
* Details of the parent and the adoptive parent, in the case of adoption by the spouse or domestic partner of a parent or another person
Given name or names and family name (including maiden name, if applicable) of the parent and of the adoptive parent:
Parent's and adoptive parent's place of birth and age at the date of birth of the child:
Parent's and adoptive parent's usual occupation:
Parent's and adoptive parent's place of residence:
* Details of the adoptive parent, in the case of adoption by one adoptive parent (other than adoption by the spouse or domestic partner of the parent)
Given name or names and family name (including maiden name, if applicable) of the adoptive parent:
Adoptive parent's place of birth and age at the date of birth of the child:
Adoptive parent's usual occupation:
Adoptive parent's place of residence:
Details of the relationship of the adoptive parents/the adoptive parent and spouse or domestic partner
Not required if the adoption order is made in respect of one adoptive parent who is not the spouse or domestic partner of a parent.
If married—
Date of the marriage:
Place of marriage:
If in a registered domestic relationship—
Date of the registration or formal recognition of the domestic relationship:
Place of registration or formal recognition of the domestic relationship:
If neither married nor in a registered domestic relationship—
Date of commencement of the relationship:
Details of other children of the adoptive parent/adoptive parents/
adoptive
parent and spouse or domestic partner [ include deceased children and
stillborn children if the information is available ]
Name or names of each child in order of birth:
Age (in years) of each child at the time of birth of the child now being registered:
*Name of the Aboriginal agency concerned in the arrangements for adoption:
The provisions of section 114 of the Adoption Act 1984 apply.
Details of the adoption order
Date of the adoption order:
The Court and the place where the order was made:
Other details
Not required if the adoption is finalised in a Convention country.
Whether the adoptive parents are related to the child and, if so, the relationship in each case:
*delete if inapplicable
FORM 18
APPLICATION UNDER SECTION 92(2) OF THE ADOPTION ACT 1984 BY ADOPTED PERSON
To: The Secretary to the Department of Justice and Community Safety
Family name of adopted person:
Given names of adopted person:
Date of birth of adopted person:
Address of adopted person:
Phone number of adopted person: Home Business
I apply for—
*(a) an extract from, or certified copy of, the entry in the Register of Births that relates to [ insert name of adopted person ]; or
*(b) a copy of an extract from, or certified copy of, the original birth certificate relating to [ insert name of the adopted person ] contained in records relating to my adoption that are in the possession or under the control of the Secretary, an agency, another body or person or of the Court.
Signature of adopted person:
Date:
*delete if inapplicable
FORM 19
APPLICATION FOR COPY OF BIRTH CERTIFICATE BY ADOPTED PERSON OR ADOPTIVE OR NATURAL PARENT
To: The Secretary to the Department of Justice and Community Safety
Family name of applicant:
Given names of applicant:
Address of applicant:
Phone number of applicant: Home Business
Family name of adopted child:
Given names of adopted child:
Date of birth of adopted child:
An order for the adoption of the child (whose birth was not registered in Victoria) has been made under the Adoption Act 1984 on [ insert date of order ] in favour of—
*a spouse or domestic partner of a natural parent of the child
*a person who, or whose spouse or domestic partner, is a relative of the child
*two persons who are relatives, or one of whom is a relative, of the child
I am—
*a person in whose favour the order was made
*the adopted person
*a natural parent of the child (where the adoption order was made in favour of the spouse or domestic partner of the natural parent)
I apply for a copy of an extract from, or certified copy of, the birth
certificate relating to *myself/*my child/*my adopted child contained in
records relating to the adoption of *myself/*my child/*my adopted child that
are in the possession or under the control of the Secretary, an agency,
another body or person or of the Court.
Signature:
Date:
*delete if inapplicable