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: info@dehoneytravel.com 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: __________________