1964_ADOPTION_RULES — Page 19

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

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)

[Hong

,本文署名者[香港

of

*

居於

› Th

parent of (2)

名爲(註二)

being the married/unmarried/widowed ()

female ) infant (hereinafter called the infant) who was born in

a male/ 之男/女

幼童 (註一) (以下稱該幼童)之已婚、未婚/已喪偶(註一)之父/母。該幼童係

在

on the

day of 出生,出生日期爲一九

年 月 日。

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

birth certificate No.

記號之出生證號碼

((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 律或行 將頒

頒發 領養 爲

to adopt the infant in accordance with the law of Hong Kong or the country in 令之國

國家 家之法 律而獲認

獲認可及 獲挑 選

which the adoption order will be made and I state as follows-

爲領養該幼童之人之領養子女。兹並聲明如下

(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

嘴

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

of the infant is being heard by the Court, this document may be used as evidence 申 請時 本文件可用以證明余

明余係同

係同意頒

>

of my consent to the making of the order unless I have notified the Director 發是項領 令者 除非余在簽立

立該同意

within 3 months from the day on which I execute this form that I no longer 書後三 個月內通知社會福利署署長不再

consent (4).

同意(註四)。

(3)

I desire that the infant shall be brought up in the

欲 該 幼

在

*(三)余

religion.

宗教信仰下教養。

奮

*Delete (3) or (4).

*删去(三)或(四)