Minor Travel Medical Consent Form

Minor's Information

Full Name

Date of Birth

Gender

Address

Parent/Guardian Information

Full Name Relationship to Minor Contact Number Email Address

Travel Information

Destination(s)

Departure Date

Return Date

Accompanying Adult(s) Name(s)

Medical Information

Allergies Current Medications Medical Conditions Health Insurance Provider & Policy Number Physician Name & Contact Information

Consent

I hereby authorize emergency medical treatment and necessary medical care for the above-named minor while traveling, if I cannot be reached in an emergency.

Parent/Guardian Signature

Date

Witness Signature

Date