To Whom It May Concern:
I/We, _______________________________________________________________________________
(Full Name(s) of Custodial and/or Non-Custodial Parent(s)/Legal Guardian(s))
am/are the lawful custodial parent and/or non-custodial parent(s) or legal guardian(s) of:
Child’s full name:_____________________________________________________________________
Date of Birth:________________________________________________________________________
Place of Birth:________________________________________________________________________
Passport Number:_________________________________________________________________
Date and Place of Issuance of Passport:________________________________________________
____________________________________, has my/our consent to travel with:
(Child’s Full Name)
Full name of accompanying person:_______________________________________________________
Passport number: _____________________________________________________________________
Date and Place of issuance of this passport:_________________________________________________
to visit_____________________________________ during the period of ________________________.
(Name of Country)
(Dates of Travel: Departure and Return)
During that period, _________________________________will be residing with
(Child’s Name)
____________________________________________________ at the following address:
(Name of Person Who Child will be Residing With at Intended Destination)
Number/Street Address& apartment number:_______________________________________________
City, State/Province, Country:___________________________________________________________
Telephone and/or Fax Number(s) (work, mobile number & residence)___________________________
Signature:__________________________ ______________________ Date:___________________
(Signature of Custodial Parent, and/or Non-Custodial Parent or Legal Guardian)
Full Name: __________________________________________________________________________
Signature:__________________________ ______________________ Date:___________________
(Signature of Custodial Parent, and/or Non-Custodial Parent or Legal Guardian)
Full Name: __________________________________________________________________________
Signed before me, ____________________________________________________________________,
(Full Name of Witness)
this_____________________ at _________________________________________________________.
(Date)
(Name of Location)
Signature:________________________________________________
Last Updated: 02/14