SAMPLE : This is a sample that was used in a case where the birth father and the adoptive mother had a relatively comfortable relationship due to visitation during the foster care placement.
The undersigned hereby agree to the following conditions as part of and a condition of the surrender for adoption of Julia Mary Miller:
First: Julia will be surrendered for adoption by her birth father Carl Miller. Julia will be adopted by her foster mother Linda Perry. If the agency becomes aware that Ms. Perry can not or will not adopt the child Julia, the agency will immediately notify Carl Miller and the agency shall follow all procedures designated under SSL §383-c and FCA §1055-a.
Second: Carl Miller, birth father of Julia, will have visitation with Julia 3 times per year – at intervals of approximately every 4 months. These visits will occur on dates and times mutually agreed upon by the two parties, Mr. Miller and Ms. Perry. At each visit the parties will consult their schedules and agree upon the date and time of the next visit. The parties will endeavor to agree to dates that are convenient for both of them and for the child. Mr. Miller may request that his visit coincide with a special or family occasion and Ms. Perry will endeavor to cooperate with such activity. All the visits will occur under the following conditions:
- The visits will be minimally one hour in length, but may be longer if the parties so agree.
- The visits will be at a location of Linda Perry’s choice. At no time shall a visit be held in a jail or a prison or an inpatient facility for mental illness or substance abuse.
- The visits will be supervised by Ms. Perry or someone she has approved of as a supervisor until such time as both parties agree that the child is comfortable with an unsupervised setting.
- If Mr. Miller can not or does not make a visit that had already been arranged for, for whatever reason, Ms. Perry is under no obligation to “make up” or offer an alternative visit. If Ms. Perry cannot or does not make a visit that had already been arranged for, the visit will be “made up” within a month’s time at a time the parties mutually agree upon. The parties will show as much consideration as possible to advise each other of visits which cannot be made.
- If Mr. Miller misses two visits within any 12 month time period, excluding a provable crisis beyond his control, such as serious illness, Ms. Perry is no longer obligated to provide any further visitation whatsoever.
- The parties shall exchange phone numbers and addresses but shall only use same to communicate regarding visits.
- All visits will be discontinued if that is the recommendation of any therapist treating the child. Visits would only then recommence upon a therapist’s recommendation and under terms recommended.
- A visit will be discontinued if Mr. Miller engages in any offensive conduct toward Julia, Ms. Perry, or anyone supervising the visit. A visit will terminate immediately if Mr. Miller appears to be under the influence of drugs or alcohol or uses same during a visit.
- Visits will be discontinued if, at any time after the child turns 12 years of age, the child states that she does not wish to visit Mr. Miller.
- At the visit, Mr. Miller will be permitted to take 2-3 photos of the child or of Mr. Miller with the child for his own use. Mr. Miller shall not display the photos in any way on any internet site or in any public media.
Third: This Agreement shall survive the adoption of Julia and shall be governed by the laws of New York State.
Fourth: This constitutes the entire agreement between birth father Carl Miller, foster and adoptive mother Linda Perry and Hudson County DSS.Source: NYSCCC conference workshop presentation by Margaret A. Burt, Esq., email@example.com. Copyright 2013, Reprinted with permission of the author.