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Form #1041Agreement for Visitation by Natural Grandparents
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AGREEMENT FOR VISITATION BY NATURAL GRANDPARENTS
A visitation
agreement was entered into on _________________(Date), between
_____________________________ and _____________________________ (Names),
husband and wife, residing at _____________________________________________ (Address),
and herein referred to as adopting parents; and _______________________Â (Name)
residing at ______________________________________________ (Address),
and herein referred to as natural mother; and _________________________________
(Name), currently residing at ______________________________________ (Address),
and herein referred to as natural father; and _______________________________
and _________________________________ (Names), currently residing at
____________ _____________________________________________________________ (Address),
the parents of ______________________________ (Name of Natural
Mother/Father), and the natural grandparents of
_______________________________ (Name), child of the natural mother and
natural father.
Â
In
consideration of this visitation agreement, and other good and valuable
consideration, the parties hereby agree as follows:
Â
1. Adopting
parents do hereby agree to formally adopt the child, __________________ (Name),
of above-named natural mother and natural father.
Â
2. Said
natural mother and natural father do hereby consent to the adoption of their
child by the above-named adopting parents.
Â
3. The parties to the agreement concur that it is in the
best interests of the child, ________________________ (Name), that
contact be maintained between the child and _________ (His/Her) natural
grandparents. The contact will consist of __________ (_____) (Number)
visits during each year between the child,
_____________________
(Name), and the natural grandparents, or either of the natural
grandparents.
4. The agreed
upon visits will commence on or about ____________(Date), at
____________________________________________________________ (Address).
Should the designated visitation site become unsuitable for visitation
purposes, the parties to this agreement will select another mutually acceptable
site.
5. This
agreement will be in effect until _________________________ (Child)
reaches the age of eighteen (18). Should this agreement prove at any time to
be detrimental to the best interests of ____________________________________ (Child),
the parties to the agreement will endeavor to cooperate fully and affect any
changes mutually agreed upon. If the parties to the agreement cannot negotiate
a mutual resolution, they hereby agree to submit to mediation in order to
resolve their dispute. The mediation will be conducted by
___________________________________________________________ (Set Forth Terms
of Mediation, as Prescribed in the Applicable Rules of the American Arbitration
Association).
Â
Dated:
________________
Â
________________________________Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â ____________________________
________________________________Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â Â ____________________________
Signatures of
Adoptive Parents                                 Signature of Natural Parents
________________________________
________________________________
Signatures of
Grandparents
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