Travel Consent For Minor Child Template


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 ______________________________
State of _______________
County of _______________
ACKNOWLEDGED BEFORE ME on this date ____________________ by _________________________.
[Notary seal]
Notary Public signature
My commission expires


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