0	)
	)
	)	IN THE MATTER OF
TO WIT:	)	CONSENT TO TRAVEL
	)	FOR
	)
	)

I, of , , 0 DO SOLEMNLY DECLARE:

1. I am the parent/guardian of:
   
   , hereby referred to as "the child";
   
   
2. I have sole legal custody of the child;
   
   
3. The child is traveling with their , , with my full knowledge and consent, for the purposes of a trip from , , 0 to ;
   
   
4. This trip will commence on or about (m/d/y) and end on or about ;
   
   
5. I appoint as the child's guardian for the purposes of consenting to emergency medical procedures, during the trip;
   
   
6. If there are any questions regarding this document, I the undersigned, can be reached via telephone at: .
   
   

AND I make this solemn declaration, conscientiously believing it to be true and knowing that it is of the same force and effect as if made under oath.

DECLARED BEFORE ME at the _______	)
of ________, in ,	)
0, this _________	)
day of _______________, _______	)	_______________________
	)
	)	_______________________
A Notary Public for	)
	)
_________________________	)