FAMILY COURT ________ CIRCUIT STATE OF HAWAI‘I CONSENT BY CHILD (AGE 10 OR OVER) TO ADOPTION Child’s Legal Name Name of Proposed Adoptive Parent(s) I, the above-named child, being Child’s Birthdate CASE NUMBER FC-A NO. Child’s Birth Place Relationship to Child years old, do consent to my adoption by the above-named person(s) who I believe will be a good parent(s) and able and willing to give me a proper home and education. I understand that once I am adopted I shall no longer be the legal child of my present legal [ ]mother [ ]father [ ]parents, but will become the child of the above-named person(s) as if I had been born to him, her or them. (In Stepparent Adoptions) However, I understand that even after the adoption is granted, I shall still be the child of my [ ]father [ ]mother, who is now married to the person wanting to adopt me. Because I believe the proposed adoption is in my best interest, I request that the Court grant this adoption and change my name to . DATE SIGNATURE OF CHILD SOCIAL SECURITY NUMBER DATE SIGNATURE OF WITNESS PRINT NAME OF WITNESS 08/07/01 CONSENT OF CHILD (AGE 10 OR OVER) TO ADOPTION American LegalNet, Inc. www.FormsWorkflow.com