AUTHORIZAT ION FOR FOREIGN TRAVEL WITH MINOR To Whom It May Concern: This letter is in relation to my child, _____________________________________________ [name of child], who is a citizen of the United States of America and a minor born on _________________________ [specify child’s date of birth]. My child holds a U.S. passport with the number _________________________. I do solemnly swear that I have legal custody of my child and that no pending divorce or child custody proceedings involving my child exist. I do hereby grant full authorization and consent for my child to travel outside of the United States with _________________________ [specify name of adult with whom child will travel], who is the _________________________ [specify adult’s relationship with child] of my child. The purpose of the travel is _________________________ [specify vacation, touring, to visit relatives, to accompany adult on business trip or other reason]. I have approved the following travel plans: Dates of travel: _________________ _________________ Destinations/Accommodations: ______________________________________ ______________________________________
I authorize _____________________________________________ [name of adult with whom child will travel] to make any changes whatsoever to the travel plans specified above. Under penalty of perjury under the laws of the state of ______________________, I attest to the truthfulness, accuracy, and validity of the forgoing statement.
____________________________________ Parent 1’s Signature
___________________ Date
____________________________________ Parent 2’s Signature Parent #1:
___________________ Date
Name: ________________________________________________________________________ Address: ______________________________________________________________________ Home phone: __________________________ Work phone: __________________________ Cell phone: ____________________________ Pager: _______________________________ Email: ________________________________ Additional Contact Information: _____________________________________________________ _______________________________________________________________________________ Parent #2: Name: ________________________________________________________________________ Address: ______________________________________________________________________ Home phone: __________________________ Work phone: __________________________ Cell phone: ____________________________ Pager: _______________________________ Email: ________________________________ Additional Contact Informatio n: _____________________________________________________ _______________________________________________________________________________
CERTIFICATE OF ACKNOWLEDGMENT OF NOTARY PUBLIC STATE OF __________________ COUNTY OF ________________ Acknowledged before me on ___________________ [date] by __________________________________ [name of principal]. [Notary Seal, if any]:
_______________________________ (Signature of Notarial Officer) Notary Public for the State of __________________ My commission expires: ______________________