Birth Parent Adoption Services Agreement Birth Parent Adoption Services AgreementThank you so much for your application! We are excited to work with you.Before we set everything in motion, we need you to complete and sign this document and return it to us as soon as you can.I, intend to place my child, born/expected to be born on with A Act of Love/Alternative Options (“Act of Love”) for the purpose of adoption.I understand Act of Love has agreed to provide services to me related to my adoption plan. I have filled out Act of Love’s Birth Parent Application to the best of my knowledge, and Act of Love has explained in full the services which can be provided to me. I understand that services are provided on a case-by-case basis, but that I will have access to all services Act of Love could provide to me.I agree to cooperate with Act of Love in the performance of services that will be provided related to my adoption plan.I agree to be forthright and honest with Act of Love, to answer all questions accurately and honestly, and to disclose to Act of Love anything that may affect any prospective adoptive placement or the security and/or development of the child that I may be required to disclose under Utah law or under the laws of the state where I will be placing my child. I also agree to update the information contained in the Birth Parent Application as changes occur.Act of Love has not promised me money or anything of value in exchange for placing my child for adoption.I acknowledge that Act of Love is bound by legal and professional obligations in the performance of professional services to me. As such, it is possible Act of Love could fail or refuse to continue to provide services if, in Act of Love’s sole opinion and discretion, it believes it should discontinue services.I understand that certain employees, agents, consultants, or independent contractors of Act of Love may provide adoption services to both me and the adoptive parents with whom I become matched. I expressly consent to have such employees, agents, consultants, or independent contractors of Act of Love provide adoption services to both me and the adoptive parents with whom I become matched.I understand Act of Love cannot guarantee that all information I provide to Act of Love will remain confidential, particularly if I choose to have some openness in my adoption. I understand that Act of Love will use reasonable care to maintain the confidentiality of my information, consistent with the level of openness I choose, but I acknowledge there are circumstances and individuals outside the control of Act of Love that may impact the ability of Act of Love to maintain the level of confidentiality I choose.I release and hold harmless Act of Love from all claims, losses, liability, actions, causes of action, damages, or injuries, no matter how characterized, related to, or arising from my actions or omissions or those of any prospective adoption parents; related to or arising from services provided by Act of Love, including, but not limited to, any breach or apparent breach of confidentiality; related to or arising from Act of Love’s discontinuance of services; or related to or arising from any decision made by Act of Love with respect to me or my child.I understand that Act of Love will place children with adoptive families of any religion, but that if a child has already achieved some identification with a particular religion or if I desire that my child be placed with a family of a particular religion, Act of Love will honor that identification or desire to the extent possible. I understand that Act of Love will do what it can to match my religious preference, but that if my religious preference cannot be met, I understand Act of Love will be free to select a family of an appropriate religious background unless otherwise specified. If you have a religious preference for the placement of your child, please mark: no preferenceCatholicProtestantLDSJewish Other I understand that Act of Love does not discriminate based on marital status, but Act of Love follows Utah law.I understand that Act of Love places children with single adoptive applicants, but that Utah law prohibits Act of Love from placing children with a single adoptive applicant who is cohabiting with another person.I understand that Act of Love will assist me with an adoption plan of my choice.I understand that Act of Love offers all levels of open and closed adoptions, but AOL cannot guarantee confidentiality of information when an open adoption is chosen.I understand Act of Love offers counseling for me, regardless of whether I choose adoption.I understand that Act of Love offers resource information for medical services.I understand that housing arrangements, transportation, medical expenses, and living expenses are available on a case-by-case basis.I understand that living expenses may include, but may not be limited to one or more of the following: housing, food, utilities, medicines, or clothing, if needed. All expenses are determined on a case-by-case basis and may be limited further by the laws of the state where the adoptive family resides where the child will be placed. Any housing provided will be on an at-will basis, meaning Act of Love may terminate the housing arrangement at-will and without cause, and upon five (5) calendar day notice.By signing these documents electronically, I/we acknowledge that the electronic mark or symbol used to sign is representative of, functionally equivalent to, and shall be treated exactly the same as my/our handwritten signature(s). By making such a mark, I/we affirm that I/we do so with the intent to sign the forms or records so marked. I/we understand that by signing these documents electronically I/we will be bound by the terms of the documents, the same as if I/we had signed with my/our handwritten signature(s). Birth Mother Signature Date Birth Father Signature (If applicable) Date A Act of Love ·9561 South 700 East, Suite 101, Sandy, Utah 84070·(801) 572-1696·Fax (801) 572-9303 24-Hour Birth Parent Line 1-800-835-6360 ©Copyright A Act of Love 2010 Please leave this field empty.