Short-Term Travel Guardianship Consent Document
Child’s Information
Full Name:
Date of Birth:
Passport/ID Number:
Guardian’s Information
Guardian Name:
Relationship to Child:
Contact Number:
Address:
Parent/Legal Guardian’s Consent
Parent/Legal Guardian Name:
Relationship to Child:
Contact Number:
Address:
Travel Information
Destination(s):
Departure Date:
Return Date:
Pertinent Medical Information:
Consent Statement
I hereby authorize the above guardian to be responsible for my child listed above for the specified travel period.
Signature of Parent/Legal Guardian:
Date:
Witness Name:
Signature:
Date: