Medical Consent for Minor Traveler

This medical consent form authorizes designated guardians to obtain medical care for a minor child when parents or legal guardians are not present.

Minor's Information

Full Name

Date of Birth

Passport/ID Number

Home Address

Parent/Legal Guardian Information

Full Name Phone Number Email Address Home Address

Authorized Caregiver/Chaperone

Full Name Relationship to Minor Phone Number

Travel Information

Destination

Departure Date

Return Date

Medical Information

Known Allergies/Conditions Current Medications Primary Physician Name Physician Phone Number

Consent Statement

Parent/Guardian Authorization

Signature

Date