Authorization for Foreign Travel With Minor

To Whom It May Concern:

This letter concerns my child, _____________________________________________ [name of child], a United States citizen and a minor born on _________________________ [child’s date of birth], who carries a United States passport with the number ____________________.
I affirm that I have legal custody of my child, and that there are no pending divorce or child custody proceedings that involve my child. I give my full authorization and consent for my child to travel outside of the United States with ____________________ [name of adult with whom child will travel], who is the ____________________ [state 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:
Dates of travel:	Destinations/Accommodations:
____________________	____________________________________________
____________________	____________________________________________
Furthermore, I hereby authorize ____________________ [name of adult with whom child will travel] to modify the travel plans specified above as he/she deems necessary.

I declare under penalty of perjury under the laws of the state of ______________________ that the foregoing is true and correct.

Parent 1’s signature: _____________________________________________________
Date: ____________________
Print name: ________________________________
Address:	______________________
______________________
Home phone: ____________________	Work phone: ____________________
Cell phone or pager: ____________________	Email: ____________________

Parent 2’s signature: _____________________________________________________
Date: ____________________
Print name: ________________________________

Certificate of Acknowledgment of Notary Public

State of _______________________________	)
	)	ss
County of _____________________________	)

On _____________________, before me, ______________________________, a notary public in and for said state personally appeared ___________________ ________________________, known to me (or proved to me on the basis of satisfactory evidence) to be the person whose name is subscribed to the within instrument, and acknowledged to me that he or she executed the same in his or her authorized capacity and that by his or her signature on the instrument, the person, or the entity upon behalf of which the person acted, executed the instrument.
	WITNESS my hand and official seal.
	_____________________________________
	Notary Public for the State of ______________
	My commission expires __________________
[NOTARY SEAL]