To whom it may concern,

I, , am the lawful custodial parent and/or non-custodial parent or legal guardian of:

 

Child’s Full Name:
Date of Birth: Jan 01, 1970
Place of Birth:

 

, has my consent to travel with:

Accompanying Guardian:
Address: , , ,
Passport Number:
Date of Issue: Jan 01, 1970
Issuing Authority:

 

to visit:

Destination:
During the period of: Jan 01, 1970 to Jan 01, 1970
Accommodations at:

 

Custodian Contact:
, , ,
Phone Number:

 

Signature: ____________________________

Name:
Date: __________________________

 

 

 

Signature: ______________________________
Notary Name: _________________________________