Travel Consent Form - Template, Sample Form to Complete

PARENTAL CONSENT FOR INTERNATIONAL TRAVEL OF A MINOR WITHOUT ADULT SUPERVISION

(Notarized Letter of Consent and Authorization)

§ 1. Declarant and Parental/Guardian Identity.

I, ________, residing at ________, holder of government-issued identification number ________ and U.S. passport number ________, being of legal age and sound mind, do hereby declare under penalty of perjury under the laws of the United States that I am the lawful parent and/or legal guardian of the minor child identified below, and that I possess full legal authority to execute this consent on the child's behalf.

§ 2. Identification of the Minor Child.

-- ________, gender: ________, born on ________ in ________, holder of passport number ________ issued by ________, expiring on ________ (the “Child”).

§ 3. Identity of Second Parent or Guardian.

The other parent or legal guardian of the Child, if any, is ________, residing at ________, who has been informed of and likewise consents to the travel described herein, as evidenced by the signature appended below or by separate written consent. Where applicable, the custody status of the Child is as follows: ________.

§ 4. Grant of Consent for Unaccompanied International Travel.

I hereby grant my full, knowing, and voluntary consent for the Child to travel internationally to ________, departing on ________ and returning on ________ (the “Travel Period”), without an accompanying parent, guardian, or other supervising adult, save for any unaccompanied-minor services provided by the carrier. This consent is given freely and is intended to satisfy the documentation requirements of immigration, customs, and transportation authorities in the United States and in the destination country.

§ 5. Travel and Transportation Details.

The travel itinerary, including carrier, flight or transit numbers, departure and arrival points, and any unaccompanied-minor program arrangements, is as follows:

________

The Child will reside or be received during the Travel Period at the following address: ________.

§ 6. Special Medical Needs and/or Allergies.

The Child has the following special medical needs, medications, conditions, and/or allergies:

________

The Child's health insurance carrier and policy number are: ________. The Child's treating physician is ________, reachable at ________.

§ 7. Authorization for Emergency Medical Treatment.

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§ 8. Emergency Contact Information.

In the event of an emergency, the following persons may be contacted:

Name: ________
Relationship to Child: ________
Phone number: ________
Address: ________

Secondary contact — Name: ________
Relationship to Child: ________
Phone number: ________

§ 9. Scope, Duration, and Revocation.

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§ 10. Indemnification.

To the fullest extent permitted by law, I agree to indemnify and hold harmless any carrier, provider, official, or responsible adult who acts in good-faith reliance upon this consent, except to the extent of such party's gross negligence or willful misconduct.

§ 11. Governing Law.

This consent shall be governed by and construed in accordance with the laws of the State of ________ and applicable federal law of the United States, without regard to its conflict-of-laws principles.

§ 12. Contact for Questions.

If there are any questions or concerns regarding this document, I may be contacted at:

________
________
________
________

§ 13. Execution.

I declare under penalty of perjury under the laws of the United States that the foregoing is true and correct.

Executed on ________ at ________.

__________________________________
________
Parent / Legal Guardian (Signature)

__________________
DATE

__________________________________
________
Second Parent / Legal Guardian (Signature, if applicable)

__________________
DATE

__________________________________
________
WITNESS

__________________
DATE

ACKNOWLEDGMENT / NOTARIZATION

State of ________ )
County of ________ )

On this ________, before me, ________, a Notary Public in and for said state, personally appeared ________, who proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument, and acknowledged to me that he/she executed the same in his/her authorized capacity, and that by his/her signature on the instrument the person executed the instrument. I certify under penalty of perjury under the laws of the State of ________ that the foregoing is true and correct.

WITNESS my hand and official seal.

__________________________________
Notary Public Signature
My commission expires: ________
(Seal)