Date:
To Whom It May Concern,
Details of Minor
Name of Minor:
Date of Birth:
Passport Number (if applicable):
Temporary Guardian Details
Relationship to Minor:
Contact Number:
Travel Information
Destination(s):
Travel Dates:
Authorization Statement
I, , parent/legal guardian of the above named minor, hereby authorize to act as temporary guardian and accompany the minor during the specified travel period.
This authorization includes making decisions regarding medical care and general welfare of the minor during the travel.
Parent(s)/Legal Guardian(s) Information
Signed at:
Date:
Signature of Parent/Legal Guardian: