1986 Ed.]
Adoption Rules
[CAP. 290
A 19
[Subsidiary]
FORM 4A
[rule 10.]
L.N.228/77.
第四甲表格
[規例第十條]
General consent of parent to an adoption order 父母同意領養令之一般同意書
I, the undersigned
余，本文署名者[香港身份證號碼
Kong Identity Card No.
ADOPTION ORDINANCE
領養子女條例
(Chapter 290)
(香港法例第二九〇章)
, being the parent of (2)
名爲(註二) a male/female infant (hereinafter called the infant) who was born in
之男/女幼童 (註一) (以下稱該幼童) being the married/unmarried/widowed ()
on the day of 出生, 出生日期爲一九 年 月 日。
I consent to the making of an adoption order under which the infant to whom the
現同意頒發領養令，以便該幼童，亦即現呈有“A”字記號之出生證號碼
birth certificate No. ((s) now produced and marked “A”
(註三)所指之人
relates, will be the adopted child of any person or persons approved and selected
成根據香港法律或將頒發領養令之國家之法律而獲認可及獲挑選
to adopt the infant in accordance with the law of Hong Kong or the country in
爲領養該幼童之人之領養子女。兹並聲明如下
which the adoption order will be made and I state as follows-
(1) I understand that upon execution of this form by me, I shall cease to
(一)余知該同意書經簽立後，余對該幼童之
have any parental rights, duties, obligations or liabilities in respect of the infant.
任何父母權利、職責、義務或責任即告終止
(2) I understand that when an application for an adoption order in respect
(二)余知當法庭聽取關於該幼童之領養令之申請時，本文件可用以證明余
of the infant is being heard by the Court, this document may be used as evidence
係同意頒發是項領養令者，除非余在簽立該同意書後三個月內通知社會福利署署長不再
of my consent to the making of the order unless I have notified the Director
同意(註四)。
within 3 months from the day on which I execute this form that I no longer
(3) I desire that the infant shall be brought up in the
(三)余欲該幼童在 宗教信仰下教養。
religion.
*Delete (3) or (4).
*删去(三)或(四)