FLR-34-E (2009/04) Page 1 of 2

ONTARIOCourt File Number

(Name of Court)

atCourt office address

Form 34: Child’s Consent to Adoption

Applicant(s) (The first letter of the applicant’s surname may be used)Full legal name & address for service — street & number, municipality, postal code, telephone & fax numbers and e-mail address (if any).

Lawyer’s name & address — street & number, municipality, postal code, telephone & fax numbers and e-mail address (if any).

Respondent(s) (If there is a respondent, the first letter of the respondent’s surname may be used)Full legal name & address for service — street & number, municipality, postal code, telephone & fax numbers and e-mail address (if any).

Lawyer’s name & address — street & number, municipality, postal code, telephone & fax numbers and e-mail address (if any).

1. My name is (chid's full legal name)

2. I was born on (give date of birth)

3. I know that the applicant(s) is/are asking the court to make an order to adopt me.

4. I agree to being adopted by the applicant(s).

5. I have been given a chance to get counselling.6. I understand the nature and effect of this consent. I understand that I may withdraw this consent within 21 days by attending

at the office of the lawyer who witnessed the consent located at (give address)

or by attending at the office of another authorized representative of the Children’s Lawyer and signing a written notice of withdrawal.

7. I understand that once I turn eighteen years old, I can apply for a copy of my original birth registration, if any, and a copy of my adoption order.

8. I understand that once I turn nineteen years old, my birth parent(s) can apply for information from my original birth registration, if any, any substituted birth registration and my adoption order. This information would include my full legal name after adoption.

9. I have spoken to a lawyer who has explained adoption to me,

who has explained what it means for me to sign this consent,

who has told me what to do if I want to change my mind about this consent,

who has told me about my rights and the rights of other persons with respect to the disclosure of adoption information,

who is going to witness my signing of this form.

To be completed only where the child is 12 years of age or older.

10. I agree that my name after adoption will be (full legal name after adoption)

Date of signature signature of child

Signature of Children’s Lawyer

Page 2 of 2FLR-34-E (2009/04)

Form 34: Child’s Consent to Adoption (page 2) Court File Number

AFFIDAVIT OF EXECUTION AND INDEPENDENT LEGAL ADVICE

My name is (full legal name)

and I swear/affirm that the following is true:

1. I am a member of the Bar of (name of jurisdiction)

and am an agent of the Office of the Children’s Lawyer.

2. I am not acting for any other person in this adoption case.

3. I explained to (child’s full legal name) aboutthe nature and effect of adoption under the law of Ontario

the nature and effect of this consent

the circumstances under which this consent may be withdrawn

his/her rights and the rights of other persons with respect to the disclosure of adoption information

in language appropriate to his/her age to the best of my knowledge and skills.

4. After my explanation, the child told me that he/she wanted to sign this consent.

5. I was present at and witnessed the signing of this consent by the child.

Sworn/Affirmed before me atmunicipality

inprovince, state or country

ondate Commissioner for taking affidavits

(Type or print name below if signature is illegible.)

Signature (This form is to be signed in front of a

lawyer, justice of the peace, notary public or commissioner for taking affidavits.)

Form 34: Child’s Consent to Adoption �

FLR-34-E (2009/04)

Disponible en français

Page  of 

Form 34: Child’s Consent to Adoption 

(page )

Page  of 

Form 4:         Notice of Change in Representation

Page 

FLR-34-E (2009/04)

Form 34: Child’s Consent to Adoption

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ONTARIO

at

Form 34: Child’s Consent to Adoption

Applicant(s) (The first letter of the applicant’s surname may be used)

Respondent(s) (If there is a respondent, the first letter of the respondent’s surname may be used)

3.     I know that the applicant(s) is/are asking the court to make an order to adopt me.

4.     I agree to being adopted by the applicant(s).

5.     I have been given a chance to get counselling.

6.     I understand the nature and effect of this consent. I understand that I may withdraw this consent within 21 days by attending at the office of the lawyer who witnessed the consent located at (give address)

           or by attending at the office of another authorized representative of the Children’s Lawyer and signing a written notice of withdrawal.

7.     I understand that once I turn eighteen years old, I can apply for a copy of my original birth registration, if any, and a copy of my adoption order.

8.     I understand that once I turn nineteen years old, my birth parent(s) can apply for information from my original birth registration, if any, any substituted birth registration and my adoption order. This information would include my full legal name after adoption.

9.           I have spoken to a lawyer 

To be completed only where the child is 12 years of age or older.

10.   I agree that my name after adoption will be (full legal name after adoption)

AFFIDAVIT OF EXECUTION AND INDEPENDENT LEGAL ADVICE

and I swear/affirm that the following is true:

1.          I am a member of the Bar of (name of jurisdiction)

         and am an agent of the Office of the Children’s Lawyer.

2.          I am not acting for any other person in this adoption case.

3.          I explained to (child’s full legal name)

about

         in language appropriate to his/her age to the best of my knowledge and skills.

4.          After my explanation, the child told me that he/she wanted to sign this consent.

5.          I was present at and witnessed the signing of this consent by the child.

Sworn/Affirmed before me at

in

on

8.0.1291.1.339988.308172

Form 34: Child’s Consent to Adoption

Form 34: Child’s Consent to Adoption

CurrentPageNumber: NumberofPages: Save Form: Print Form: Clear Form: TextField: 2Court File Number: Court File Number: TextField1: Name of Court. Select from the drop down menu.: Court office address: Respondent(s). Lawyer’s name & address — street & number, municipality, postal code, telephone & fax numbers and e-mail address (if any).: Child’s full legal name: I was born on (give date of birth): his/her rights and the rights of other persons with respect to the disclosure of adoption information: Date of signature: Signature of Children’s Lawyer: municipality: province, state or country: date: Commissioner for taking affidavits(Type or print name below if signature is illegible.): commissioner: