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INSTRUCTIONS FOR PARENTAL/GUARDIAN APPROVAL FOR MINOR TO TRAVEL (Cass County Michigan Courts)

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INSTRUCTIONS FOR
PARENTAL/GUARDIAN APPROVAL FOR
MINOR TO TRAVEL AND MEDICAL AUTHORIZATION
If one legal parent is traveling outside the United States with a
minor child, this form should be signed by the legal parent that is
not
traveling.
If a minor child is traveling outside the United States with someone
other than either legal parent,
BOTH
legal parents should sign this
form.
If one or both legal parents are deceased, a certified death
certificate should be attached to this form. If one of the legal
parent’s whereabouts is unknown, a separate affidavit stating such
is suggested.
Note:
Most countries do not require these forms, but it is in the best interest of the traveling
parent, the absent parent, and child to have the information available to authorities. In any case, the
medical instructions are a good idea. It is the traveler’s ultimate responsibility to verify entry and exit
requirements of all destinations. This is not to be construed as legal advice and is only to be considered a
best practice.
JOINT PARENTAL/GUARDIAN APPROVAL FOR
MINOR TO TRAVEL AND MEDICAL AUTHORIZATION
I,
_______________________________ , AM THE LEGAL MOTHER / FATHER / GUARDIAN (CIRCLE ONE) OF
THE MINOR CHILDREN WHOSE NAMES AND BIRTHDATES ARE AS FOLLOWS: [USE ADDITION PAGE AS
NECESSARY]
NAME: ______________________________________ DOB: _________________________ AGE: _________
NAME: ______________________________________ DOB: _________________________ AGE: _________
NAME: ______________________________________ DOB: _________________________ AGE: _________
I, _______________________, LEGAL MOTHER / FATHER /GUARDIAN OF THESE CHILDREN, AGREE THAT THE
LEGAL FATHER / MOTHER GUARDIAN _______________________ SHALL HAVE PERMISSION TO TRAVEL
ACROSS INTERNATIONAL BORDERS WITH OUR CHILDREN, PROVIDED THAT ALL INFORMATION REGARDING
ITINERARY AND CONTACT INFORMATION IS PROVIDED ON THIS FORM, AND MY NOTARIZED
ACKNOWLEDGMENT OF RECEIPT OF ITINERARY IS ATTACHED TO THIS MINOR CHILD CONSENT TO TRAVEL
AND MEDICAL AUTHORIZATION ]
I APPROVE TRAVEL FOR MY CHILD AS FOLLOWS:
NAME: ______________________________________ DOB: _________________________ AGE: _________
NAME: ______________________________________ DOB: _________________________ AGE: _________
NAME: ______________________________________ DOB: _________________________ AGE: _________
TRAVELING TO __________________________________________________________
COMPLETE ITINERARY:
USE ADDITIONAL SHEET (S) as NECESSARY
Date: Complete Contact Information:
Address, Telephone No, etc.
From ________________ (date) to
________________ (date)
Date: Complete Contact Information:
Address, Telephone No, etc.
From ________________ (date) to
________________ (date)
Date: Complete Contact Information:
Address, Telephone No, etc.
From ________________ (date) to
________________ (date)
(Destination or Type of Travel) _____________________________________________
FROM (Departure Date) ______________________ TO (Return Date) ________________________
DEPARTURE LOCATION
_________________________ RETURN LOCATION _____________________________
WITH ___________________________________________________________________
____________________________________________ (Traveling Adult’s Full Name)
I ALSO AUTHORIZE THE TRAVELING ADULT TO OBTAIN ANY NECESSARY MEDICAL TREATMENT BY A
LICENSED PHYSICIAN/ HOSPITAL/PHARMACY/ RESCUE SQUAD/ AMBULANCE COMPANY / MEDICAL AIR
EVACUATION COMPANY.
IN THE EVENT THE TRAVELING ADULT IS INCAPACITATED AND CANNOT GIVE AUTHORIZATION FOR
TREATMENT, I AUTHORIZE A LICENSED PHYSICIAN/ HOSPITAL/ PHARMACY/ RESCUE SQUAD, AMBULANCE
COMPANY /MEDICAL AIR EVACUATION COMPANY TO GIVE MY CHILD(REN) ANY NECESSARY MEDICAL
TREATMENT. I CAN BE REACHED AT ______________________________________________________
(Telephone Numbers)
HOWEVER, I DO WANT TREATMENT TO COMMENCE PRIOR TO MY BEING CONTACTED IF MY CHILD(REN) IS IN
PAIN OR THE CONDITION IS LIFE THREATENING.
SIGNATURES:
Legal Mother Printed Name _____________________ Signature ____________________
Legal Father Printed Name ______________________ Signature ____________________
Legal Guardian Printed Name _________________ Signature ___________________
I, hereby certify that ___________________________ and/or ______________________
(Legal Mother, Father or Guardian) (Legal Mother, Father or Guardian)
personally appeared before me and executed this document giving permission for the child(ren)
named above to travel out of the United States of America with the Traveling Adult named above.
This document also includes authorization of medical treatment for the child if necessary. I attest that
this instrument is executed willingly and voluntarily, without being coerced, by the above signor(s),
and it is their free act and deed for the purposes of expressing their approval. In the circumstance of
one parent or both parents being deceased or that the legal parents do not have child custody, I
attest that the surviving parent or legal guardian swore to the accuracy of the death certificate(s)
and/or guardianship documents attached to this document in my presence.
Date: _________________________________
Notary Public Signature:
_________________________________
County of
_________________________________
State or Commonwealth of
_________________________________
My commission expires:
_________________________________
EXHIBIT A
LEGAL CUSTODY OF THE MINOR CHILD(REN) IS AS FOLLOWS:
____ MOTHER & FATHER SHARE JOINT LEGAL CUSTODY
____ MOTHER HAS SOLE LEGAL CUSTODY
____ FATHER HAS SOLE LEGAL CUSTODY
____ OTHER (SPECIFY) _____________________________________________________
PHYSICAL CUSTODY OF THE MINOR CHILD(REN) IS AS FOLLOWS:
____ MOTHER & FATHER SHARE JOINT PHYSICAL CUSTODY
____ MOTHER HAS SOLE PHYSICAL CUSTODY
____ FATHER HAS SOLE PHYSICAL CUSTODY
____ OTHER (SPECIFY) _______________________________________________________
STATE IN WHICH CURRENT CHILD CUSTODY ORDER HAS BEEN ENTERED:
_______________________________________
STATE WITH “HOME STATE JURISDICTION” OVER MINOR CHILDREN:
_______________________________________
COUNTRY OF HABITUAL RESIDENCE OF THE MINOR CHILDREN:
_______________________________________
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INSTRUCTIONS FOR PARENTALGUARDIAN APPROVAL FOR MINOR TO TRAVEL (Cass County Michigan Courts)

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Completed 6 June 2021

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