Minor's Abortion Parental/Guardian Notification Form for Kansas
If you are seeking an abortion and are under the age of 18 you must do one of the following:
1. Have a parent/guardian sign and notarize our Parental Notification Form.
We have a Notary here; or,
2. Have a Certified Notification Letter mailed to your parent or guardian and
received by them notifying them that you may choose to have an abortion. The green return-slip
is what we must have, and once received, they cannot stop the abortion; or,
3. Do a Judicial By-pass to Parental Notification. If the previous options will
cause a hardship or further injury, a Kansas District court judge can waive (avoid) this
notification requirement with the help of a free, court-appointed, attorney by authority of
K.S.A. 65-6705. After you have done your sonogram and counseling with us you will call the
attorney given by us. Once this is done, they cannot stop the abortion.
With options 1 and 2 we need to prove your parentage by birth certificate or guardianship by
court documents. The minor and 21 year-old-or-older always need acceptable photo ID. The 21
year-old-or-older is only needed for the counseling.
I, (print parent or guardian name) _____________________________________,
am the mother, father, or legal guardian of (print minor patient name)
_______________________________________ and I have been notified that my daughter may
choose to have an abortion.
_________________________________________
Notarized parent or guardian signature
State of ______________________ )
) Sworn and Sealed
County of _____________________ )
Now before me, Notary in and for this County and State, personally appeared _________________________________,
who being duly sworn, executed this Limited Power of Attorney as their free act and deed.
IN TESTIMONY WHEREOF, I have subscribed my name and affixed my official seal this _____ day
of _______________________, 20___.
________________________________________
Notary public's signature