Fill and Sign the Travel Consent Form

International Travel Consent for a Minor (with Affidavit) and Authorization for Minor to Receive Medical Treatment I, ________________________________ ( First, Middle, Last Name of Parent) hereby authorize my minor child ________________________________ (First, Middle, Last Name) to travel out of the United States from (date) _____________ to (date)______________ traveling to the country of _____________________ under the custody of ________________________________ (First, Middle, Last Name. I also authorize my said minor child to receive any necessary medical treatment while traveling in the custody of the above mentioned person. _____________________________________ Parent ฀s Signature STATE OF ___________________ COUNTY OF _________________ UNITED STATES OF AMERICA Personally appeared before me, the undersigned authority in and for the jurisdiction aforesaid, the within-named _________________________________, who, being by me first duly sworn according to law, states on oath that the contents of the above and foregoing International Travel Consent for a Minor (with Affidavit) and Authorization to Receive Medical Treatment are true and correct as therein stated and set forth. __________________________________ Signature of Parent SWORN TO AND SUBSCRIBED Before Me on this the ____ day of ____________, 20_____. __________________________________ Notary Public My Commission Expires:_____________________