Parental Consent Forms For Minor Children Traveling Without Both Birth Parents Page 2
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4AFFIDAVIT OF PARENTAL CONSENT
For Travel Outside The United States Of A Minor Child
Without Both Birth Parents Traveling
FORM # 1 - BOTH BIRTH PARENTS ARE ALIVE • PLEASE TYPE OR PRINT CLEARLY!
I, ____________________________________________________________________________________________ [a]
____________________________________________________________ [b] Of Said Minor Child, Do Hereby Authorize
______________________________________________________________________________________________ [c]
_______________________________________________________ [d] Of Said Minor Child To Travel As A Guardian Of
_______________________________________________________________________________ [e], Age: ________ [f]
To The Following Countries Without ____________: [g]
______________________________________________________________________________________________ [h]
______________________________________________________________________________________________ [h]
From: Day: __________ / Month: __________ / Year: __________ [i]
To:
Day: __________ / Month: __________ / Year: __________ [j]
[k] I/We [ _ ] HAVE; [ _ ] DO NOT HAVE Major Medical Insurance that will cover this child for medical treatment outside
the United States; and that I/We [ _ ] AUTHORIZE; [ _ ] DO NOT AUTHORIZE the above named person to make medical
treatment decisions for the minor child listed above if needed. If not, we have provided Emergency Contact Information
below:
Name: __________________________________________________________________________________________
Address: ________________________________________________________________________________________
City / State / Zip: __________________________________________________________________________________
Home Phone: ( _____ ) ____________________________ Work Phone: ( _____ ) ____________________________
Alternate Name & Phone: ___________________________________________________________________________
________________________________________________________________________________________________
Signature: ______________________________________________________________
(Signature Of Non-Traveling Birth Parent(s) • To Be Signed In Front Of A Notary Public Only)
Subscribed and sworn to before me this ______ day of __________________________, 200___
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
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