Parental Consent Forms for Minor Children travelling without parent(s)

Parental Consent Forms for Minor Children
travelling without parent(s)
Should a child be traveling across borders or even locally for a once-off excursion with a school or
organization, you can use the stand-alone attached parental travel consent forms:
“AUTHORIZATION FOR FOREIGN TRAVEL WITH MINOR”
“AUTHORIZATION FOR MINOR'S MEDICAL TREATMENT”
At times it may be impossible to get hold of parents in an emergency situation, so your authorization
forms granting permission to authorize medical treatment can prevent serious delays (or simply issue
a separate parental medical consent form in the case of the child being looked after by a child
minder).
IMPORTANT INFORMATION
•
These forms should be notarized, but you should not sign them beforehand since the public
notary or commissioner of oath must witness your signature. Make sure to take all
identification documents along - your own as well as your child's (e.g. birth certificate Note: if
one parent on the birth certificate of the child is deceased you should provide a certified copy
of the death certificate)
•
If the child's surname is different from the parent you may need a marriage certificate, name
change document, adoption papers etc. to prove the relationship
•
The organizers of an excursion, field trip or sports tour will usually issue their own forms
requesting information as well as indemnifying them against claims. If you do not agree with or
understand any particular clause you should take it up with them. If they do not ask for details
such as allergies or current medication you should add it as a footnote or as an (attached)
addendum. If you know your child's blood group you can add that too.
•
A parent may need these parental travel consent forms from the other parent if he / she does
not have legal custody or even if they have joint legal custody
•
If a parent does have sole legal custody, he / she should have a certified copy of the court
document when traveling across international borders
•
To avoid administrative hassles during an emergency you should attach a copy of your
Medical Aid or Health insurance to your Free Temporary Guardianship Form
•
Make sure you initial wherever details are filled in or wherever alterations are made with full
signatures at the end
•
Witness signatures must be by independent persons and not by anybody listed on the free
temporary guardianship form / agreement
Dehoney Travel 3008 Charlestown Crossing New Albany, IN 47150
Phone (812)206-1080 or (800)325-6708
Fax (812)206-1085
www.dehoneytravel.com
e-mail: [email protected]
AUTHORIZATION FOR FOREIGN TRAVEL WITH MINOR
To Whom It May Concern:
This letter is in relation to my child, _____________________________________________ [name of child], who is a
citizen of the United States of America and a minor born on _________________________ [specify child’s date of birth].
My child holds a U.S. passport with the number _________________________.
I do solemnly swear that I have legal custody of my child and that no pending divorce or child custody proceedings
involving my child exist. I do hereby grant full authorization and consent for my child to travel outside of the United States
with _________________________ [specify name of adult with whom child will travel], who is the
_________________________ [specify adult’s relationship with child] of my child. The purpose of the travel is
_________________________ [specify vacation, touring, to visit relatives, to accompany adult on business trip or other
reason]. I have approved the following travel plans:
Dates of travel:
_________________
_________________
Destinations/Accommodations:
______________________________________
______________________________________
I authorize _____________________________________________ [name of adult with whom child will travel] to make
any changes whatsoever to the travel plans specified above.
Under penalty of perjury under the laws of the state of ______________________, I attest to the truthfulness, accuracy,
and validity of the forgoing statement.
____________________________________
Parent 1’s Signature
___________________
Date
____________________________________
Parent 2’s Signature
___________________
Date
Parent #1:
Name: ________________________________________________________________________
Address: ______________________________________________________________________
Home phone: __________________________
Work phone: __________________________
Cell phone: ____________________________
Pager: _______________________________
Email: ________________________________
Additional Contact Information: _____________________________________________________
_______________________________________________________________________________
Parent #2:
Name: ________________________________________________________________________
Address: ______________________________________________________________________
Home phone: __________________________
Work phone: __________________________
Cell phone: ____________________________
Pager: _______________________________
Email: ________________________________
Additional Contact Information: _____________________________________________________
_______________________________________________________________________________
CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC
STATE OF __________________
COUNTY OF ________________
Acknowledged before me on ___________________ [date] by __________________________________ [name of
principal].
[Notary Seal, if any]:
_______________________________
(Signature of Notarial Officer)
Notary Public for the State of __________________
My commission expires: ______________________
AUTHORIZATION FOR MINOR'S MEDICAL TREATMENT
Child
Full Legal Name: ___________________________________________________________________
Date of Birth: _______________________
Age: ___________
Gender: ___________
Doctor’s Information
Doctor’s Name: ____________________________________________________________________
Doctor’s Address: __________________________________________________________________
Doctor’s Office Phone: ____________________ Doctor’s Emergency Phone: __________________
Medical Insurer/Health Plan: __________________________
Policy #: ______________________
Allergies to Medications: _____________________________________________________________
Allergies (Other): ___________________________________________________________________
If applicable, please note the conditions for which the child is currently receiving treatment:
_________________________________________________________________________________
Note any other significant medical information:
_________________________________________________________________________________
_________________________________________________________________________________
Dentist’s Information
Dentist’s Name: ____________________________________________________________________
Dentist’s Address: __________________________________________________________________
Dentist’s Office Phone: ____________________ Dentist’s Emergency Phone: __________________
Dentist’s Insurer/Health Plan: __________________________
Policy #: _____________________
Parent(s)/Legal Guardian(s):
Parent #1:
Name: ___________________________________________________________________________
Address: ________________________________________________________________________
Home phone: __________________________
Work phone: ____________________________
Cell phone: ____________________________
Pager: _________________________________
Email: ________________________________
Additional Contact Information: _______________________________________________________
_________________________________________________________________________________
Parent #2:
Name: ___________________________________________________________________________
Address: ________________________________________________________________________
Home phone: __________________________
Work phone: ____________________________
Cell phone: ____________________________
Pager: _________________________________
Email: ________________________________
Additional Contact Information: _______________________________________________________
_________________________________________________________________________________
Alternate contact in the event Parent(s)/Legal Guardian(s) cannot be reached:
Name: ___________________________________________________________________________
Address: ________________________________________________________________________
Home phone: __________________________
Work phone: ____________________________
Cell phone: ____________________________
Pager: _________________________________
Email: ________________________________
Additional Contact Information: _______________________________________________________
_________________________________________________________________________________
AUTHORIZATION AND CONSENT OF PARENT(S) OR LEGAL GUARDIAN(S)
I do hereby solemnly swear that I have legal custody of the aforementioned minor child.
I grant my authorization and consent for _________________________________________ (hereafter “Supervising
Adult”) to administer general first aid treatment for any minor injuries or illnesses experienced by the minor. If the injury or
illness is life threatening or in need of emergency treatment, I authorize the Supervising Adult to summon any and all
professional emergency personnel to attend, transport, and treat the participant and to issue consent for any X-ray,
anesthetic, blood transfusion, medication, or other medical diagnosis, treatment, or hospital care deemed advisable by,
and to be rendered under the general supervision of, any licensed physician, surgeon, dentist, hospital, or other medical
professional or institution duly licensed to practice in the state in which such treatment is to occur.
It is understood that this authorization is given in advance of any such medical treatment, but is given to provide authority
and power on the part of the Supervising Adult in the exercise of his or her best judgment upon the advice of any such
medical or emergency personnel.
This authorization is effective commencing on the ______day of ____________________, 20_____ and expiring on the
______day of ____________________, 20____.
Signed this ______day of____________________, 20 ____.
______________________________________
Parent #1’s Signature
______________________________________
Parent #2’s Signature
CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC
STATE OF __________________
COUNTY OF ________________
This document was acknowledged before me on ______________________ [date] by
________________________________________________ [name of principal].
[Notary Seal, if any]:
_______________________________
(Signature of Notarial Officer)
Notary Public for the State of ______________
My commission expires: __________________