I, , hereby declare that I am the parent of the following child:
Full name:
Date of birth:
Place of birth:
Birth certificate:
Date of issue:
I authorize the child to travel from till to the following destination: . The address of the accommodation is .
I allow the child to travel with the following individual:
Nationality:
Passport:
Date of issue:
Issuing authority:
Any questions regarding this document may be addressed to me at:
, .
Emergency contact. In case I am not available, please contact at , .
Signed on .
_____________________________
(Place for signature)
Notary Acknowledgment
State of
Sworn to and subscribed before me on
Acting in the county of
_____________________________
Notary public's name and seal
