S.I. No. 19/1965 - Adoption Rules, 1965.

We, the undersigned, being a married couple living together, desire to adopt the child named or described in this application form. We understand that if an adoption order is granted to us in respect of the child, we shall be fully responsible for the child's upbringing as if the child were born to us in lawful wedlock and we voluntarily undertake to discharge that responsibility as far as we are able. We have not received or made, or agreed to receive or make, any payment whatsoever in consideration of the adoption of this child.*

Husband's signature .....................................................

Wife's signature ............................................................ 

Date ............................................................ .............

*Payments made or received in respect of the child's maintenance or solicitors' remuneration for professional services are not referred to here.

(To be completed where the application is being made by one person only)

Strike out the parts that do not apply.

I, the undersigned person, being the mother of the child/the natural father of the child/a relative* of the child/a widow

Strike out the parts that do apply.

desire to adopt the child named or described in this application form. I understand that if an adoption order is granted to me in respect of the child, I shall be fully responsible for the child's upbringing as if the child were born to me in lawful wedlock and I voluntarily undertake to discharge that responsibility as far as I am able. I have not received or made, or agreed to receive or make, any payment whatsoever in consideration of the adoption of this child.†

Applicant's signature...........................................................

Date. ............................................................ ........

*"relative" here means grandparent, brother, sister, uncle or aunt, whether of the whole blood, of the half blood, or by affinity, relationship to an illegitimate child being traced through the mother only.

† Payments made or received in respect of the child's maintenance or solicitors' remuneration for professional services are not referred to here.

(To be completed in every application. If the application is being made by a married couple, the particulars given should be those relating to the husband only.)

1. Husband's /Applicant's name. (Strike out "husband's" or "applicant's", whichever does not apply)

............................................................ ............................................................ ............................................................ ..

(Block letters.)

2. Address............................................................ ............................................................ ...........................................

(Block letters.)

3. Occupation............................................................ ............................................................ ......................................

4. Relationship (if any) to child............................................................ ............................................................ ........

5. Date of birth ............................................................ ............................................................ ...................................

6. Are you ordinarily resident in the State and, if so, since when? ............................................................ .......

............................................................ ............................................................ ............................................................ ...

7. Religious denomination ............................................................ ............................................................ ................

(This section is to be completed only where the application is being made by a married couple. The questions relate to the wife.)

8. Wife's name............................................................ ............................................................ ......................................

(Block letters.)

9. Relationship (if any) to child............................................................ ............................................................ .........

10. Date of birth............................................................ ............................................................ ...................................

11. Are you ordinarily resident in the State and, if so, since when?............................................................ .......

............................................................ ............................................................ ............................................................ ...

12. Date and place of marriage ............................................................ ............................................................ .........

13. Religious denomination ............................................................ ............................................................ ...............

14. Have you previously applied for an adoption order in respect of this or any other child and, if so, with what result?............................................................ ............................................................ ............................

............................................................ ............................................................ ............................................................ ...

............................................................ ............................................................ ............................................................ ...

15. (a) Have you any children of your own; if so, please give names, dates of birth and present addresses?............................................................ ............................................................ .............................................

............................................................ ............................................................ ............................................................ ..

............................................................ ............................................................ ............................................................ ...

............................................................ ............................................................ ............................................................ ..

............................................................ ............................................................ ............................................................ ..

(b) Have you any other children in your care; if so, please give names and dates of birth?............................................................ ............................................................ ....................................................

............................................................ ............................................................ ............................................................ ..

............................................................ ............................................................ ............................................................ ..

............................................................ ............................................................ ............................................................ ..

............................................................ ............................................................ ............................................................ ...

16. Christian name of child to whom this application refers............................................................ ................

............................................................ ............................................................ ............................................................ ...

(Block letters.)

17. Sex............................................................ ............................................................ ................................................

18. Date of birth ............................................................ ............................................................ ...............................

19. Name and address of person or body from whom you got the child.........................................................

............................................................ ............................................................ ............................................................ .

20. Date on which you took the child under your care............................................................ ...........................

21. Please give the names and addresses of two or more persons (either men or women) to whom reference may be made by the Board............................................................ ........................................................

............................................................ ............................................................ ............................................................ .

............................................................ ............................................................ ............................................................ .

(Block letters.)

NOTE:—The Board may require you to submit a medical certificate on your state of health before coming to a decision on your application.

NOTE TO APPLICANT:—If you got the child from the mother or guardian you should fill this Form yourself. If you got the child from any other source you may fill this Form yourself or you may send it to the person or body who gave you the child and ask him to fill it and return it direct to the Registrar, An Bord Uchtála.

1. Christian Name of Child ............................................................ ............................................................ ...........

(Block letters.)

2. Sex ...........................................................

3. Date of birth ............................................................ ............................................................ ...............................

4. Is the child an orphan (both parents dead)? ............................................................ ....................................

............................................................ ............................................................ ......................................................

5. Is the child illegitimate ............................................................ ............................................................ ..............

6. Did the child's natural parents marry each other after the child's birth?

............................................................ ............................................................ ......................................................

(NOTE:—If the answer is "yes", the Board will require further information later but, at this stage, no details need be given).

7. If the child is an orphan, state

(a) Father's name ............................................................ ............................................................ ....................

(b) Approximate date of father's death ............................................................ ...........................................

(c) Father's religion at death ............................................................ ............................................................ 

(d) Mother's name ............................................................ ............................................................ ..................

(e) Approximate date of mother's death ............................................................ ..........................................

(f) Mother's religion at death ............................................................ ..........................................................

8. If the child is illegitimate, state

(a) Mother's name............................................................ ............................................................ ...................

(b) Is the mother alive or dead............................................................ ..........................................................

(c) If alive, state

(i) her address............................................................ ............................................................ .............

(ii) occupation............................................................ ............................................................ ................

(iii) date of birth, or if date unknown, her approximate age............................................................ .

(iv) religious denomination ............................................................ ....................................................

(v) whether the mother changed her religion at any time, if so, in what way, and give date of change............................................................ ............................................................ ......................

(d) If the mother is dead, state

(i) approximate date of death............................................................ .........................................

(ii) ordinary place of residence before her death............................................................ ...............

(Block letters)

(iii) place of death

(Block letters)

(iv) religious denomination at death............................................................ .......................................

(v) whether she had changed her religion at any time and, if so, particulars and date of change............................................................ ............................................................ .......................

............................................................ ............................................................ .................................

............................................................ ............................................................ .................................

9. Name of person or persons, if any, who has or have been appointed by will or deed or by Court Order to be the guardian(s) of the child ............................................................ .....................................................

............................................................ ............................................................ ............................................................ .....

(Block letters)

10. Address(es) of guardian(s) named in answer to question 9

............................................................ ............................................................ ............................................................ .....

............................................................ ............................................................ ............................................................ .....

............................................................ ............................................................ ............................................................ .....

(Block letters)

11. If the child is or has been under the control of a Health Authority or Registered Adoption Society state name and address of Health Authority or Registered Adoption Society and date on which such body acquired control over the child.

12. Religion in which the child is being brought up ............................................................ ..............................

............................................................ ............................................................ ............................................................ .....

Signature............................................................ .............

Address............................................................ ..............

............................................................ ............

Date............................................................ .....................

(For use by mother where the identity of the applicant is known to her)

In the matter of an application for the adoption of

I............................................................ ............... of............................................................ ........................., aged twenty-one years and upwards (or, if under age, aged......... years), make oath and say as follows:—

1. I am aware that an application is about to be made or has been made by.................................................

of...................................................

for an adoption order in respect of the child............................................................ ........................................

2. I am the mother of the child.

3. The child is not less than six months old, having been born on the ......................................................... .................................... day of.................................., 19............................................................ ..........................

4. I am of the.......................................religion, and this has been my religion since......................................

5. I understand that the effect of an adoption order is to deprive me of all rights which I have in respect of the upbringing of the child, and to give these rights and all parental rights and duties to the adopter.

6. I hereby give my consent to the making of an adoption order in pursuance of the application referred to above.

7. I understand that this affidavit may be used as evidence that I consent to the adoption order being made.

Signature............................................................ ..................

Sworn at...........................in the county of.................................on this ................................................ day of..........................., 19......, before me,............................................................  (name) and I know the deponent (or and I know..............................................who certifies to me that he knows the deponent).

Signature............................................................ .....................

Description (a)

(a) If the affidavit is being sworn in the State, it should be sworn before a Commissioner for Oaths; if it is being sworn elsewhere, it should be sworn before a Notary Public or other person duly authorised to administer oaths.

(For use by persons other than mother where the identity of the applicant is known to the consenting party).

In the matter of an application for the adoption of............................................................ ..................................

I,.......................................... (name and description) of.....................aged twenty-one years and upwards (or, if under age, aged...... years), make oath and say as follows:—

1. I am aware that an application is about to be made or has been made by .................................... of .......................................... for an adoption order in respect of the child ................................................

2. I am/the father of the child/the guardian of the child/the person having charge of or control over the child/(a).

3. The child is not less than six months old, having been born on the...................... day of..............., 19......

4. I am of the.......................... religion (to be completed by the father only.)

5. I understand that the effect of an adoption order is to deprive me of all rights which I have in respect of the upbringing of the child, and to give these rights and all parental rights and duties to the adopter.

6. I hereby give my consent to the making of an adoption order in pursuance of the application referred to above.

7. I understand that this affidavit may be used as evidence that I consent to the adoption order being made.

Signature

Sworn at........................................... in the county of............................................................ ...................... on this ...........................day of................................., 19............... before me, ............................................................ ......... .............................................(name) and I know the deponent (or and I know...................................................... ..................................................who certifies to me that he knows the deponent).

Signature

Description (b)

(a) Delete words which do not apply.

(b) If the affidavit is being sworn in the State, it should be sworn before a Commissioner for Oaths; if it is being sworn elsewhere, it should be sworn before a Notary Public or other person duly authorised to administer oaths.

(For use by mother where the identity of the applicant is not known to her)

In the matter of an application for the adoption of............................................................ ......................

I,............................................................ , of.............................. aged twenty-one years and upwards (or, if under age, aged............ years), make oath and say as follows:—

1. I am informed and believe that an application has been made under serial number ................................... (a) for an adoption order in respect of the child .............................................

2. I am the mother of the child.

3. The child is not less than six months old, having been born on the.................. day of ............, 19............

4. I am of the........................ religion, and this has been my religion since

5. I understand that the effect of an adoption order is to deprive me of all rights which I have in respect of the upbringing of the child, and to give these rights and all parental rights and duties to the adopter.

6. I hereby give my consent to the making of an adoption order in pursuance of the application referred to above.

7. I understand that this affidavit may be used as evidence that I consent to the adoption order being made.

Signature............................................................ ...................................................

Sworn at............................................................ ...... in the county of..........................................................on

this..........................................day of....................................., 19....................., before me, ............................................................ ....................................... (name) and I know the deponent (or and I know............................................................ .........................who certifies to me that he knows the deponent).

Signature

Description (b)

(a) Where the identity of the applicant is not known to the consenting party the applicant should request the Board to assign a serial number to the application and this number should be inserted here.

(b) If the affidavit is being sworn in the State, it should be sworn before a Commissioner for Oaths; if it is being sworn elsewhere, it should be sworn before a Notary Public or other person duly authorised to administer oaths.

(For use by persons other than mother where the identity of the applicant is not known to the consenting party)

In the matter of an application for the adoption of............................................................ ................................

I,....................................... (name and description) of........................................ aged twenty-one years and upwards (or, if under age, aged years) make oath and say as follows:—

1. I am informed and believe that an application has been made under serial number ........................ (a) for an adoption order in respect of the child............................................................ ..................................

2. I am/the father of the child/the guardian of the child/the person having charge of or control over the child/(b).

3. The child is not less than six months old, having been born on the................. day of ................, 19.........

4. I am of the.............................. religion (to be completed by the father only).

5. I understand that the effect of an adoption order is to deprive me, of all rights which I have in respect of the upbringing of the child, and to give these rights and all parental rights and duties to the adopter.

6. I hereby give my consent to the making of an adoption order in pursuance of the application referred to above.

7. I understand that this affidavit may be used as evidence that T consent to the adoption order being made.

Signature............................................................ .................................

Sworn at............................................................ .. in the county of............................................ on this...................................... day of.........................................., 19......, before me, .............................. (name) and I know the deponent (or and I know............................., who certifies to me that he knows the deponent).

Signature

Description (c)

(a) Where the identity of the applicant is not known to the consenting party the applicant should request the Board to assign a serial number to the application and this number should be inserted here.

(b) Delete words which do not apply.

(c) If the affidavit is being sworn in the State, it should be sworn before a Commissioner for Oaths; if it is being sworn elsewhere, it should be sworn before a Notary Public or other person duly authorised to administer oaths.

WHEREAS an application has been made to An Bord Uchtála (hereinafter called "the Board") by.............................. by occupation........................ and resident at.............................. and his wife* ................................. hereinafter called the applicant/applicants* for an adoption order under the Adoption Acts, 1952 and 1964 (hereinafter called "the Acts"), authorising him/her/them* to adopt .............................. *born on the.............................. /*the probable date of whose birth has been determined by the Board to be the............................................................ .....................................................

AND WHEREAS the Board is satisfied that the requirements of the Acts with regard to the qualifications and suitability of the applicant/each of the applicants* to adopt the child and to the eligibility of the child to be adopted by the applicant/applicants* have been fulfilled or is of opinion that such requirements are likely to be fulfilled before the expiration of the probationary period mentioned hereunder:

AND WHEREAS all the consents required by the Acts have been obtained or dispensed with in accordance with the provisions of the Acts:

AND WHEREAS the Board is satisfied that the child is identical with.............................. to whom the entry numbered.............................. made on the............ day of.............................., 19......, in the Register of Births for the District of................................. in the County of...................................... relates:

NOW, THEREFORE, the Board orders as follows:—

1. This application shall stand adjourned until further order;

2. The applicant/applicants* shall have custody of the child for a probationary period beginning on the.............................. and ending on the.....................subject to the following conditions:*

GIVEN under the Official Seal of the Board this............................................................ ...

day of..........................., 19......

Chairman/Registrar/a person authorised by the Board to attest the Seal of the Board.*

*Delete words which do not apply.

WHEREAS an application has been made to An Bord Uchtála (hereinafter called "the Board") by.............................. by occupation........................... and resident at............................................. and his wife*........................ hereinafter called the applicant /applicants* for an adoption order under the Adoption Acts, 1952 and 1964 (hereinafter called "the Acts"), authorising him/her/them* to adopt.............................* born on the.............................. /* the probable date of whose birth has been determined by the Board to be the............................................................ .....................:

AND WHEREAS the Board is satisfied that the requirements of the Acts with regard to the qualifications and suitability of the applicant/each of the applicants* to adopt the child and to the eligibility of the child to be adopted by the applicant/applicants* have been fulfilled:

AND WHEREAS all the consents required by the Acts have been obtained or dispensed with in accordance with the provisions of the Acts:

AND WHEREAS the Board is satisfied that the child is identical with.............................. to whom the entry numbered.............................. made on the............... day of.............................., 19......, in the Register of Births for the District of............................... in the County of...............................relates:

NOW, THEREFORE, the Board orders the adoption of the child by the applicant/applicants*.

GIVEN under the Official Seal of the Board this............... day of.............................., 19......

Chairman/Registrar/a person authorised by the Board to attest the seal of the Board*.

*Delete words which do not apply.

WHEREAS an application has been made to An Bord Uchtála (hereinafter called "the Board") by.............................. by occupation................................ and resident at .............................. and his wife*.............................. hereinafter called the applicant/applicants* for an adoption order under the Adoption Acts, 1952 and 1964 (hereinafter called "the Acts"), authorising him/her/them* to adopt .............................. *born on the............................../*the probable date of whose birth has been determined by the Board to be the ............................................................ ..........................................................:

AND WHEREAS the Board is satisfied that the requirements of the Acts with regard to the qualifications and suitability of the applicant/each of the applicants* to adopt the child have been fulfilled:

AND WHEREAS the Board is satisfied that in the particular circumstances of this case it is desirable to make an adoption order notwithstanding that the child was more than seven years of age at the date of the application for this order and is satisfied that the case is one to which paragraph (a)/(b)* of subsection (1) of section 3 of the Adoption Act, 1964 , applies:

AND WHEREAS the Board is satisfied that the child is otherwise eligible to be adopted by the applicant/applicants*:

AND WHEREAS the Board has given due consideration to the wishes of the child having regard to his/her* age and understanding:

AND WHEREAS all the consents required by the Acts have been obtained or dispensed with in accordance with the provisions of the Acts:

AND WHEREAS the Board is satisfied that the child is identical with............................. to whom the entry numbered..............................made on the............... day of.............................., 19..., in the Register of Births for the District of.............................. in the County of..............................relates:

NOW, THEREFORE, the Board orders the adoption of the child by the applicant/applicants*.

GIVEN under the Official Seal of the Board this............... day of.............................., 19......

Chairman/Registrar/a person authorised by the Board to attest the seal of the Board.*

*Delete words which do not apply.

WHEREAS an application has been made to An Bord Uchtála (hereinafter called "the Board") by.............................. by occupation..........................., and resident at.............................. and his wife*...................... hereinafter called the applicant/applicants* for an adoption order pursuant to the Adoption Acts, 1952 and 1964 (hereinafter called "the Acts"), authorising him/her/them* to adopt.............................. *born on the........................ /* the probable date of whose birth has been determined by the Board to be the ............................................................ ................................:

*AND WHEREAS on reasonable cause being shown by the applicant/applicants* the Board extended the time for making the application:

AND WHEREAS the Board is satisfied that the child has been under the care of the applicant/applicants* from a date before the passing of the Adoption Act, 1952 , and that the requirements of the Acts with regard to the qualifications and suitability of the applicant/each of the applicants* to adopt the child and to the eligibility of the child to be adopted by the applicant/applicants* have been fulfilled:

AND WHEREAS the Board has given due consideration to the wishes of the child having regard to his/her* age and understanding:

AND WHEREAS all the consents required by the Acts have been obtained or dispensed with in accordance with the provisions of the Acts:

AND WHEREAS the Board is satisfied that the child is identical with............................. to whom the entry numbered............................. made on the.............................. day of.............................., 19....... in the Register of Births for the District of.............................. in the County of.....................relates:

NOW, THEREFORE, the Board orders the adoption of the child by the applicant/applicants.

GIVEN under the Official Seal of the Board this............... day of.............................., 19......

Chairman/Registrar/a person authorised by the Board to attest the seal of the Board*

*Delete words which do not apply.

I, the undersigned person, being duly authorised on behalf of the adoption society called.......................................... hereby apply to An Bord Uchtála (hereinafter called "the Board") to have the society registered under the Adoption Acts, 1952 and 1964, as an adoption society. The following are particulars of the society:

1. Address of society's headquarters............................................................ .................................................

(Block letters).

2. Date of establishment............................................................ ............................................................ .......

3. Objects of the society. [A copy of the society's constitution or other instrument (if any governing its activities should be attached]............................................................ .........................................................

4. Full names, addresses, occupations and/or descriptions of

(a) all members of the Committee controlling the activities of the society and

}

(a)

attach separate lists

(b) all persons employed by the society, whether voluntary or paid, on work connected with adoption.

}

(b)

5. Has the society under its control any home, hostel, orphanage or other such institution in which children under the age of seven years are maintained?

6. If the answer to question 5 is "yes", state

(a) The address of such institution............................................................ ............................................................ ......................................................

(b) Whether it is exclusively an institution for children (if not, give brief particulars) and whether it is exclusively for boys or exclusively for girls ............................................................ ............................

(c) Number of children for whom accommodation and care can be provided in the institution ............................................................ ............................................................ .................................................

(d) Approximate number of children normally in the institution ............................................................ ....

(e) In what religion the children are brought up............................................................ ...............................

(f) How the institution is mainly financed............................................................ ........................................

(g) Whether the society, if registered, propose to concern themselves only with the children in this institution (if not, give brief particulars) ............................................................ ......................................

............................................................ ............................................................ .................................................

7. If the answer to question 5 is "no", state briefly how the society propose to function as a registered adoption society—in what children they propose to interest themselves or in what circumstances do they propose to arrange adoptions ............................................................ ............................................................ ..........................................................

............................................................ ............................................................ ..............................................

The society hereby undertake, if registered, to make available to the Board when requested, in relation to any and every child with whose proposed adoption, the society is concerned, all material facts known to the society relating to the child, and to the proposed adopters, for the assistance and guidance of the Board prior to the making of an adoption order.

I, ............................................................ .........., do solemnly and sincerely declare that the foregoing particulars stated in this application are true and I make this solemn declaration conscientiously believing the same to be true and by virtue of the Statutory Declarations Act, 1938 .

Signature............................................................ .............

Office held in the society..............................................

Address............................................................ ...............

Date............................................................ ......................

Declared before me (a) ................................................... by the said applicant who is personally known to me (or who is identified to me by............................................................  who is personally known to me) at............................................................ ............................................................ ............................................................ ....

Signed............................................................ ....................................................

Description............................................................ ............................................

This............................. day of....................................., 19..............

(a) This declaration should be made before a Notary Public or a Commissioner for Oaths or a Peace Commissioner.

Memorandum to be furnished by a registered adoption society to a mother, father or guardian who proposes to place a child at the disposal of a registered adoption society.

If an adoption order is made in respect of the child, all your rights and duties in regard to the child will be transferred permanently to the adopters. The child will be regarded as the child of the adopters and you will have no right to get it back later on, even if you can then prove that you are able to give it a better home than the adopters can. If you have an insurance policy against funeral expenses for the child, the policy will be transferred to the adopters and it will be for them to pay the premiums from then onwards. If the child is illegitimate and the natural father is making any payments for the child's benefit, either under an agreement or under an affiliation order, he will not be legally bound to continue these payments, unless the mother is the adopter.

The Board which deals with adoptions will not make an adoption order without the consent of

(a) the mother of the child,

(b) the father of the child (in the case of any child who has been legitimated by the marriage of its parents), and

(c) any person appointed by will or deed or by Court Order to be the child's guardian,

unless the mother, father or guardian, as the case may be, cannot be found or is unable to give consent because of mental infirmity.

In order to ensure, therefore, that you will be informed of any proposal to have the child adopted, you should notify the society of any change in your address. If you do not do this, it may not be possible to trace you, and the adoption order may be made without your consent.

(Perforate on this line).

............................................................ ............................................................ ............................................................ ..

(Detach here).

To the registered adoption society called............................................................ .....................................................

............................................................ ............................................................ ............................................................ ......

I have received from you a statement explaining the effects of an adoption order. That statement was attached to this receipt and I have myself torn it off. I understand that statement.

Name in (block letters............................................................ ....................................................

Signature............................................................ ............................................................ .............

Address............................................................ ............................................................ ...............

............................................................ ............................................................ ............

Signature of Witness ............................................................ .................................................

Address............................................................ ............................................................ ...............

............................................................ ............................................................ ............

Occupation or Description............................................................ ..........................................

Date............................................................ ............................................................ ......................

In pursuance of the powers vested in it by the Adoption Acts, 1952 and 1964, An Bord Uchtála has made an order for the adoption of a child .................................... (here insert Christian name of child) by ............................................................ .... (here insert name(s) and address of adopter(s)).

An Bord Uchtála has registered ............................................................ ............................................................ .........

in the Adoption Societies Register.

An Bord Uchtála has cancelled the registration of .......................................................... in the Adoption Societies Register.

It has been represented to An Bord Uchtála that you can give evidence in the matter of an application for an adoption order by............................................................ ..........................................................

You are hereby required to attend as a Witness on the hearing of the said application to be held at.......................................... on the..................day of.............................., 19........, at.................. o'clock and on any day to which the hearing of the said application shall be ordered, and to bring with you the following documents............................................................ ............................................................ .........................

............................................................ ............................................................ ............................................................ ...

............................................................ ............................................................ ............................................................ ....

GIVEN under the Official Seal of the Board this ............................................................ ....... day of ....................., 19.......

Chairman/Registrar/a person authorised by the Board to attest the Seal of the Board*

To ............................................................ ............................................................ .........................................................

............................................................ ............................................................ .......................................................

............................................................ ................................................... *Delete words which do not apply.

NOTE: If you do not obey this Summons you are liable on summary Conviction to a fine not exceeding Twenty-five Pounds.

............................................................ ............................................................ ................................

(SURNAME FIRST IN BLOCK LETTERS)

of ............................................................ ............................................................ ...........................

............................................................ ............................................................ ...............................

on this date and on the basis of my examination I give the following answers to the questions set out below:—

1. Is the applicant suffering from any functional disorder or organic disease?

............................................................ .........................................

2. If so, please give particulars

............................................................ .........................................

3. Do you consider that the applicant is, as far as health is concerned, suitable to adopt a child?

............................................................ .........................................

Signed............................................................ ........................................

Address............................................................ ......................................

Date............................................................ ...........................................