Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
At times it may be impossible to get hold of parents in an emergency situation, so your authorization
forms granting permission to authorize medical treatment can prevent serious delays (or simply issue
a separate parental medical consent form in the case of the child being looked after by a child
minder).
IMPORTANT INFORMATION
• These forms should be notarized, but you should not sign them beforehand since the public
notary or commissioner of oath must witness your signature. Make sure to take all
identification documents along - your own as well as your child's (e.g. birth certificate Note: if
one parent on the birth certificate of the child is deceased you should provide a certified copy
of the death certificate)
• If the child's surname is different from the parent you may need a marriage certificate, name
change document, adoption papers etc. to prove the relationship
• The organizers of an excursion, field trip or sports tour will usually issue their own forms
requesting information as well as indemnifying them against claims. If you do not agree with or
understand any particular clause you should take it up with them. If they do not ask for details
such as allergies or current medication you should add it as a footnote or as an (attached)
addendum. If you know your child's blood group you can add that too.
• A parent may need these parental travel consent forms from the other parent if he / she does
not have legal custody or even if they have joint legal custody
• If a parent does have sole legal custody, he / she should have a certified copy of the court
document when traveling across international borders
• To avoid administrative hassles during an emergency you should attach a copy of your
Medical Aid or Health insurance to your Free Temporary Guardianship Form
• Make sure you initial wherever details are filled in or wherever alterations are made with full
signatures at the end
• Witness signatures must be by independent persons and not by anybody listed on the free
temporary guardianship form / agreement
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:
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 Date
Parent #1:
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 Information: _____________________________________________________
_______________________________________________________________________________
STATE OF __________________
COUNTY OF ________________
_______________________________
(Signature of Notarial Officer)
Doctor’s Information
Doctor’s Name: ____________________________________________________________________
Doctor’s Address: __________________________________________________________________
Doctor’s Office Phone: ____________________ Doctor’s Emergency Phone: __________________
Medical Insurer/Health Plan: __________________________ Policy #: ______________________
Allergies to Medications: _____________________________________________________________
Allergies (Other): ___________________________________________________________________
If applicable, please note the conditions for which the child is currently receiving treatment:
_________________________________________________________________________________
Note any other significant medical information:
_________________________________________________________________________________
_________________________________________________________________________________
Dentist’s Information
Dentist’s Name: ____________________________________________________________________
Dentist’s Address: __________________________________________________________________
Dentist’s Office Phone: ____________________ Dentist’s Emergency Phone: __________________
Dentist’s Insurer/Health Plan: __________________________ Policy #: _____________________
Parent(s)/Legal Guardian(s):
Parent #1:
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 Information: _______________________________________________________
_________________________________________________________________________________
I do hereby solemnly swear that I have legal custody of the aforementioned minor child.
It is understood that this authorization is given in advance of any such medical treatment, but is given to provide authority
and power on the part of the Supervising Adult in the exercise of his or her best judgment upon the advice of any such
medical or emergency personnel.
This authorization is effective commencing on the ______day of ____________________, 20_____ and expiring on the
______day of ____________________, 20____.
______________________________________
Parent #1’s Signature
______________________________________
Parent #2’s Signature
STATE OF __________________
COUNTY OF ________________
_______________________________
(Signature of Notarial Officer)