International Child Travel Consent And Acknowledgement Form
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1
2International Travel Consent and Acknowledgement
I,
{NON-TRAVELLING PARENT/GUARDIAN FIRST LAST
NAME}, make oath and state
that I am the
{MOTHER/FATHER/GUARDIAN}
and shared legal guardian of:
Child –
{CHILD’S FIRST LAST
NAME}({MALE/FEMALE}), born
{CHILD’S BIRTH
DATE}
in the United States.
{CHILD’S FIRST LAST NAME}
1)
has my consent to travel with
{TRAVELLING
PARENT/GUARDIAN FIRST LAST
NAME},
({MOTHER/FATHER/GUARDIAN}
of
child) and shared legal guardian of above mentioned minor child.
2) This consent is valid for travel starting on or about
{START DATE OF TRIP}
to
{
TRAVEL DESTINATION}
and returning on or about
{END DATE OF
TRIP}.
3) I authorize and recommend
{TRAVELLING PARENT FIRST LAST
NAME}, to make
emergency medical decisions on our behalf, in the event that my child requires
emergency medical treatment at a time or place from which I may not be reached.
4) I authorize and recommend
{TRAVELLING PARENT FIRST LAST
NAME}, to make
arrangements and determinations for all modes of travel, including itinerary changes as
necessary during this trip.
5) In the absence of
{TRAVELLING PARENT FIRST LAST
NAME}, should any medical,
travel or personal welfare incident arise, immediate contact shall be made to me,
{NON-
TRAVELLING PARENT FIRST LAST
NAME}. If immediate communication is not
possible, these decisions are to be made by
{THIRD PARTY CONTACT FIRST LAST
NAME},
({THAT PERSONS RELATIONSHIP TO
CHILD}) or
{ANOTHER THIRD
PARTY CONTACT FIRST LAST NAME} ({RELATIONSHIP TO CHILD})
who will
be traveling with the above mentioned child in
{DESTINATION
COUNTRY}.
Signed_________________________________________________
NON-TRAVELLING PARENT/GUARDIAN FIRST LAST NAME}
NON-TRAVELLING PARENT/GUARDIAN ADDRESS 1}
NON-TRAVELLING PARENT/GUARDIAN ADDRESS 2}
NON-TRAVELLING PARENT/GUARDIAN PHONE NUMBER}
NON-TRAVELLING PARENT/GUARDIAN PHONE NUMBER 2}
Notary Public Signature/Seal:
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