I am interested in placing 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 understand and agree that neither Act of Love nor its officers, directors, agents, or employees may be held liable in any way for any occurrence in connection with the provision of any services to me by A Act of Love, which may result in injury, death, or other damages to me or my family, heirs, or assigns, including damage to my personal property.
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, whether or not contemplated at the present time, 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.
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 cohabitating 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.
I understand that if a problem should arise that I am unable to resolve with an Act of Love staff member, a written grievance should be submitted to the Act of Love Governing Board as soon as possible, but in no event later than 30 days after the problem arises.
I further state that I am legally competent to sign this affirmation and release; that I understand the terms herein; and that I have signed this document as my own free act.
Utah law requires that we inform you of the following
consumer rights that you have:
You have a right to privacy of information and privacy for current and closed records. Act of Love shall take reasonable precautions to ensure the privacy of your confidential information as required by Utah law, unless you expressly agree to Act of Love’s disclosure of such information to a third party. This assurance of privacy also applies to both current and closed records.
You have the right to obtain the reasons for involuntary termination of services and the criteria for re-admission to the program. If Act of Love terminates its agreement to provide services to you and you notify Act of Love within a reasonable time period that services were discontinued against your will, within 20 business days of when Act of Love receives such notification you are entitled to a written explanation of the reasons for involuntary termination of services as well as notice of the criteria for re-admission to the program if re-admission is deemed feasible.
You have the right to freedom from potential harm or acts of violence to you or others.
You have the right to be free from unlawful discrimination.
You have the right to be treated with dignity.
You have the right to communicate by telephone or in writing with your family, attorney, physician, clergyman, and counselor or case manager, except when contraindicated by a licensed clinical professional.
You have the right to send and receive mail providing that security and general health and safety requirements are met.
You have the responsibility to be honest and forthright in your dealings with the agents, employees, and other clients of Act of Love.
You have the responsibility to never act in a way that would jeopardize or compromise the safety of any person or property while receiving services from Act of Love.
Smoking is not allowed on any property owned, leased, or managed by Act of Love.
Service fees and costs are usually born by the adoptive families. Birth parents usually do not pay any fees, but we will advise you if your situation presents different circumstances and present you with a schedule of fees and costs.
Grievance and complaint procedures. If you believe that an agent or representative of Act of Love has violated your consumer rights, you may send a written complaint to: Act of Love, Consumer Rights Complaint, 9561 South 700 East, Suite 101, Sandy, Utah 84070. Act of Love will initially attempt to resolve the matter formally with you. Act of Love may make such informal efforts for up to 60 days. If Act of Love is not able to informally resolve the complaint, you will receive a written response within twenty business days after Act of Love has ended its efforts to resolve the matter informally.
I/we, certify to the best of my knowledge that I/we have read the foregoing, I/we understand it, and I/we am/are signing this
Please release to A Act of Love/Alternative Options and Services for Children (“Act of Love”), or any employee or agent of Act of Love, 9561 South 700 East, Suite 101, Sandy, Utah, 84070, copies of all my medical records, including, but not limited to charts, notes, evaluations, test results, invoices and similar documents that you have in your possession as are described below. These records are needed by Act of Love in connection with an adoption of my child. I hereby release and absolve you from any and all liability for providing such information to Act of Love.
I understand that this information may include, when applicable, information relating to sexually transmitted disease, Human Immunodeficiency Virus (HIV infection, Acquired Immune Deficiency Syndrome or AIDS Related Complex) and any other communicable disease. It may also include information about behavioral or mental health services, and referral or treatment for substance use disorder (as permitted by 42 CFR Part 2).
This disclosure and use is for the following purpose: Adoption matter.
This information may be disclosed to and used by the following categories of persons or organizations.
Attorney(s) for adoptive parent(s) Adoptive parent(s)
Agency for adoptive parent(s) Court in connection with adoption, as necessary
Interstate Compact on the Placement of Children, as necessary
I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing and present my written revocation to youment. I understand that the revocation will not apply to my insurance company when the law provides my insurer with the right to contest a claim under my policy. Unless otherwise revoked, this authorization will expire one year from the signature date.
I understand that authorizing the disclosure of this health information is voluntary. I also understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment for services, or eligibility for benefits.
By signing this Authorization, I understand that any disclosure of information carries with it the potential for an unauthorized redisclosure and the information may not be protected by federal privacy rules. I further understand I have the right to receive a copy of this signed authorization. I understand and agree that a photo-copy
