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AFFIDAVIT OF PARENTAL CONSENT

For Travel Outside The United States Of A Minor Child - Without Both Birth Parents Traveling

PLEASE TYPE OR PRINT CLEARLY & USE ONLY FULL LEGAL NAMES

I / WE , _____________________________________________________ Mother / Father / Legal Guardian

_______________________________________________________ Mother / Father / Legal Guardian

Of Said Minor Child:______________________________________________Age: ________ / Birthdate: _______________

Do Hereby Authorize To Travel As A Guardian Of Said Minor Child:____________________________________ (relationship)

To The Following Countries Without me / us

ON A

cruise / air & land vacation

__________________________________________________________________________________________________________________

From:

Day: __________ / Month: _______________ / Year: __________

To:

Day: __________ / Month: _______________ / Year: __________

(answer and circle appropriate choices below)

I / We HAVE / DO NOT HAVE

Major Medical Insurance that will cover this child for medical treatment outside the United States;

I / We AUTHORIZE / DO NOT AUTHORIZE

the above named person to make medical treatment decisions for the minor child listed above if

needed. Below is our Emergency Contact Information:

Name: __________________________________________________________________________________

Address:_________________________________________________________________________________

Phone: ( _____ ) ___________________________

Signature: _______________________________________________________________________________

(Signature Of Non-Traveling Birth Parent(s) / Legal Guardian • To Be Signed In Front Of A Notary Public Only)

Name: __________________________________________________________________________________

Address:_________________________________________________________________________________

Phone: ( _____ ) ___________________________

Signature: _______________________________________________________________________________

(Signature Of Non-Traveling Birth Parent(s) / Legal Guardian • To Be Signed In Front Of A Notary Public Only)

Name: __________________________________________________________________________________

Address:_________________________________________________________________________________

Phone: ( _____ ) ___________________________

Subscribed and sworn to before me this ________ day of ______________________________, 20___

Signature Of Notary Public: _________________________________________________________________

Notary Public in and for the County of __________________________________, And the State Of ________

My Commission Expires: _______________________

Affix Notary Seal At The Right Side Of Page in space provided.

Affidavit Of Parental Consent Form - For Travel Outside The United States Of A Minor Child - Without Both Birth Parents Traveling