PARENTAL AUTHORIZATION FOR MINORS
(Children under 18 years old)
I, the undersigned,
Mr
and
Mrs
Capacity (parents or legal guardians)
(Both parents or guardians should provide a copy of his / her ID card with signature and the child
birth cerficate. If separated or divorced, or in case of adopon, the legal guardian should provide a
copy of the judgement.)
having full and complete custody of
Name of minor
Date of birth (day/month/ year):
Residing at
do hereby authorize my child to leave the United States of America,
from (day/month/year) to (day/month/year)
FORM TO BE NOTARIZED WITH BOTH PARENTS SIGNATURE
Place : _________________________
Date : _________________________
Mother Signature _________________________
Father Signature _________________________
(CITY and STATE)