I, {Adopter's Name}, by the affixing of my signature below, do hereby take responsibility of the one known as {Adoptee's Name}. Any and all requirements, including but not limited to, food, clothing, and protection will be provided by me from this day forward. 

 

{Adoptee's Name} will have all rights and privileges granted to any holding my name. 

{Adopter's Name} Date: 

 

{Scribe's Name} Date: