To Whom it May Concern:

I, ____________________, is We, ____________________ and ____________________, are the legal guardians of ____________, born ________.I/We acknowledge that my/our child is traveling and has my/our consent and permission to travel with ________________________, my/our child’s _____.
________________________’s passport is issued by __________ , passport number __________, issued on ____________ and by ________________________ .

On this trip, our child will be traveling to:
• ______________________
on the following dates:
_____/____/________ to _____/____/________
for the following reason(s):
____________________ .
Our child will be residing at the following address:
____________________________, _____________, _____________, _____________, _____________, _____________, _____________.
During the time period of the trip, we authorize ________________________ to seek, obtain and consent to ____________________ for ____________________ as deemed necessary by a licensed medical or healthcare professional.

Any questions regarding this consent can be directed to us at the contact information attached. In addition, a copy of proof of my sole custody is attached.

_______________________________	_______________________________
_______________________________	_______________________________

Information about Travelling Child
Full Legal Name of Child: __________________
Date of Birth: ________________
Place of Birth: _______ _______ _______
Birth Certificate Registration: _______________
Issuing Authority of Birth Number: ___________

Certificate
day / ______ month / ________ year________ state ______________ city ______________
country ______________

Child’s Passport Details
Passport Number: ____________________
Place of Passport Issuance: ____________________

Passport Country of Issue: ____________________
Date of Passport: ____________________

Child’s Health Information
Health Conditions (e.g. Asthma, Diabetes): 　_________________
Allergies (e.g. to Medications, Food): 　_________________
Prescription Medications: 　_________________
Date of Last Tetanus Injection/Booster: 　_________________

Child’s Medical Care and Insurance Information
Physician/Pediatrician: 　_________________
Phone Number:　　_________________
Dentist/Orthodontist:　　_________________
Phone Number:　　_________________
Preferred Medical Facility:　 ______________________________________
Insurance Company:　　_________________
Policy/Group Number:　　_________________
Policy Holder:　　_________________

Parent/Guardian’s Information
Parent’s/Guardian’s Name: 　_____________________________________________
Address: 　___________, ____________, ____________, ____________
• Phone Number: ____________ ()
Email:　____________
Parent’s/Guardian’s Name: 　_____________________________________________
Address: 　___________, ____________, ____________, ____________
Address: 　___________, ____________, ____________, ____________
Phone Number : ____________ ()
Email:　____________

Emergency Contact Person’s Information
Emergency Contact’s Name: 　_____________________________________________
• Phone Number: ___________________ (_)
Email:　___________________

Alternative Emergency Contact Person’s Information
Emergency Contact’s Name:　__________________________________
• Phone Number: ___________________ (_)
Email:　___________________

WITNESS SIGNATURES

I hereby acknowledge that the foregoing Child Travel Consent was signed by _______________ _______________ and in my presence.

Witness

Name (please print)
Signature
Date

Name (please print)
Signature
Date

NOTARY ACKNOWLEDGEMENT OF PRINCIPAL

STATE OF ___________________________ )

) (seal)

COUNTY OF _________________________ )

The foregoing instrument was acknowledged before me this _________ day of ______________________, 20_____, by the undersigned, _______________, _______________, who is personally known to me or satisfactorily proven to me to be the person whose name is subscribed to the within instrument.

_______________________________
Signature

_______________________________
Notary Public

My Commission Expires: ________________