Minor Travel Consent with Medical Authorization

Minor Information

Name of Minor: Date of Birth: Passport/ID Number:

Parent/Legal Guardian Information

Name of Parent/Guardian: Relationship to Minor: Phone Number: Email Address:

Accompanying Adult (if applicable)

Name: Relationship to Minor:

Travel Details

Destination(s): Travel Dates (From - To): Purpose of Travel:

Medical Authorization

I authorize necessary medical treatment for the above-named minor while traveling outside my care.

Medical Insurance Provider: Policy Number: Known Allergies/Conditions:

Signatures

Parent/Guardian Signature: Date: