Notary Form for Child Travel

Parent/Guardian Information

Full Name:

Address:

City/State/Zip Code:

Phone Number:

Email:

Child Information

Full Name:

Date of Birth:

Passport Number (if applicable):

Country of Issuance (if applicable):

Travel Information

Destination(s):

Travel Dates:

Purpose of Travel:

Accompanying Adult Information

Full Name:

Relationship to Child:

Passport Number (if applicable):

Contact Information:

Authorization

I, Parent/Guardian Full Name hereby authorize Accompanying Adult’s Nameto travel with my child, Child’s Full Name to the destination(s) specified above on the travel dates listed. This authorization is granted for the specified period only and for the purpose of ensuring my child's safe travel.

Parent/Guardian Signature

Date:

Notary Public Section

State of:
County of:

On this _______ day of _________, 20, before me, the undersigned, personally appeared Parent/Guardian Full Nameknown to me or satisfactorily proven to be the person who signed the foregoing instrument, and acknowledged that they executed the same for the purposes therein contained.

Notary Public Signature

Commission Expires:

Seal

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