Medical Consent for Minors Travel
Minor's Information
Full Name
Date of Birth
Gender
Passport/ID Number
Parent/Legal Guardian Information
Full Name(s)
Relationship to Minor
Contact Number
Email Address
Address
Travel Details
Destination(s)
Purpose of Travel
Departure Date
Return Date
Accompanying Adult(s) Name(s)
Relationship to Minor
Medical Information
Allergies/Medical Conditions
Medications
Primary Physician Name & Contact
Insurance Provider & Policy Number
Consent Statement
I/We, the undersigned parent(s) or legal guardian(s), authorize necessary medical treatment for the minor listed above during the travel period specified.
Signatures
Parent/Guardian Signature
Date
Parent/Guardian Signature
Date
Witness/Notary (if required)
Name
Signature
Date