Travel Consent For Minor Child Template printable pdf download

TRAVEL CONSENT FOR MINOR CHILD

1. I, _________________________ (parent name) am the father [ ] mother [ ] of my minor child,

_________________________ (child’s name), male [ ] female [ ],

born on ____________________ (date of birth),

born at ______________________________ (place of birth, city, state),

bearing US passport number ____________________, issued on ___________________ (date),

hereby referred to as "my child".

2. I am the lawful custodian of my child.

3. I give my consent for my child to travel with his/her father [ ], mother [ ], other adult [ ],

_________________________ (accompanying adult’s name), with my full knowledge.

4. The trip is from ______________________________ (departing city, state, country) to

______________________________ (destination city, state, country)

5. At the destination, my child will be staying at address _______________________________________

with ______________________________ (family, friend, group, accompanying adult),

the contact phone number at the destination is ______________________________.

6. The trip will begin on or about ____________________ (departure date) and end on or about

____________________ (return date);

7. The primary means of travel is by ___________________ (automobile, airplane, train, bus, ship, other).

Name of airline, train, bus, ship _________________________

departure number __________, return number __________

8. I authorize the accompanying adult as my child's guardian for the purposes of making any decisions

and consenting to any routine, urgent or emergency medical procedures, for my child during the trip.

9. My child has the following medical condition, prescription, or allergy:

________________________________________

10. If there are any questions regarding this document, I can be reached by telephone at

_______________ (phone number) or email ______________________________.

11. I make this consent, knowingly and willingly, for the purposes stated.

Print name ______________________________

Street Address ______________________________

City, State, Zip ______________________________

_________________________

____________________

Signature

Date

=================================================================================

State of _______________

County of _______________

ACKNOWLEDGED BEFORE ME on this date ____________________ by _________________________.

_________________________

[Notary seal]

Notary Public signature

_________________________

My commission expires

Travel Consent For Minor Child Template