Consent for International Travel Without Supervision

I, ________, of ________, declare that I am the parent/legal guardian of the following child:

-- ________, Male, born on ________ in ________, passport number ________

My child has consent to travel to ________ from ________ to ________, without an adult present.

Special Medical Needs and/or Allergies

My child has the following special medical needs and/or allergies:

-- ________

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

________
________
________
________

__________________________________
________


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WITNESS


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