Notarized Medical Treatment Consent for Traveling Minor

Minor’s Information

Full Name
Date of Birth
Passport/ID Number
Address

Parent/Legal Guardian Information

Full Name
Relationship to Minor
Contact Number
Address

Trip Details

Destination(s)
Travel Dates

Accompanying Adult (if applicable)

Full Name
Relationship to Minor
Contact Number

Consent Statement

I, the undersigned parent or legal guardian of the minor named above, hereby authorize any licensed physician, medical provider, or healthcare facility to provide any necessary medical care or treatment to the minor during travel as described above.

Health Insurance Information (if applicable)

Provider Name
Policy Number
Signature of Parent/Guardian
Date

Notarization

Subscribed and sworn to me before this ______ day of ______________, 20____.
Notary Public
My Commission Expires