[Your home address]
[Your daytime telephone number]
To whom it may concern.
I, the undersigned, having sole parental responsibility for [insert child’s current full name here] consent to [his/her] name being changed to [insert new full name here].
For the purpose of changing my [son/daughter’s] name, I hereby delegate parental responsibility to [related person’s full name] [of address – if different to mother’s] who is my [son/daughter’s] [state relationship to child].
[Your full name] Mother