At Pirate and Mermaid Vacations we believe that travel is one of the great adventures of life. Sometimes we let our minor children travel with friends, family, or other non-custodial adults.

You are receiving this form because your minor child is traveling with non-custodial adults and we want to ensure that they have a safe and enjoyable time. This form will provide your authorization for your child to travel with a non-custodial adult and for their chaperones to provide appropriate medical care if it may be needed.

This form will be provided to your child's chaperone for use while traveling and to you as well for your records. Also, we care about the privacy of your child's personally identifiable information, so please be assured that we will not share this information with any other parties except as required by law.

Pirate and Mermaid Vacations

CONSENT TO TRAVEL WITH AND SEEK MEDICAL TREATMENT FOR MINOR CHILDREN


To Whom It May Concern:

I, , parent or legal guardian of , born on in

With U.S. passport number: issued on by

Has my consent to travel with:  

To visit:  

During the period of to .

In the event that my child requires medical attention I also hereby consent to any medical care and the administration of anesthesia determined by a physician to be necessary for the welfare of my child while they are under the care of the above-named adult chaperone and I am not reasonably available by telephone to give consent.

This authorization is effective only during the dates above.

This consent form should be taken with the child to the hospital or physician's office when the child is taken for treatment. This additional information will assist in treatment if it can be furnished with the consent but is not required.

Parent's telephone numbers:  

Last Tetanus: (Please note your child's travel may require additional imunizations, consult https://travel.state.gov for more information)

Allergies:

Special Medications, Blood Type or Pertinent Information:

Child's Physician:

Phone:

Insurance company:

Policy #

Leave this empty:

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Signature Certificate
Document name: CONSENT TO TRAVEL WITH AND SEEK MEDICAL TREATMENT FOR MINOR CHILDREN
lock iconUnique Document ID: be1b970adc655a700a938ac82d23f7c7396f6db0
Timestamp Audit
2018.11.29 11:40 PM ESTCONSENT TO TRAVEL WITH AND SEEK MEDICAL TREATMENT FOR MINOR CHILDREN Uploaded by Andrew Shumate - andrew.shumate@pirateandmermaid.vacations IP 12.227.80.226