Commonwealth of Massachusetts Rev.13462E6 CHILD TRAVEL CONSENT FORM I, Stallone Delorme, am the parent/legal guardian of Stallone Delorme, born June 06, 2022. I acknowledge that my child is traveling internationally and has my consent and permission to travel with l am god sham., our child’s please go to the child.. TRIP DETAILS CHILD’S NAME: Stallone Delorme ACCOMPANYING PERSON: l am god sham. TRAVEL DESTINATION: When you are a man.; TRAVEL DATES: May 30, 2022 to May 30, 2022 PURPOSE: - A business trip with parents RIGHT TO WITHDRAW TRAVEL CONSENT If at any time, the travel destination becomes under a Level Four Travel Advisory, as determined by the Center for Disease Control or under a Level Three (or Higher) Travel Advisory by Homeland Security, we have the right to withdraw our travel consent immediately upon written notification of the same. MEDICAL CONSENT I grant our authorization and consent for l am god sham. to administer general first aid treatment for any minor injuries or illnesses experienced by the Minor Child. If the injury or illness is life threatening or in need of emergency treatment, we authorize l am god sham. to summon any and all professional emergency personnel to attend, transport, and treat the Minor Child and to issue consent for any X-Ray, anesthetic, blood transfusion medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licenses physician, surgeon, dentist, hospital, or other medical professional or institution duly licenses to practice in the state or country in which such treatment is to occur. I agree to assume financial responsibility for all expenses of such care. This authorization for medical treat specifically excludes these following treatments due to religious beliefs: - Skin grafts - Heart Transplant - Any Treatment containing animal products Child Travel Consent Form (Rev. 13462E6) 1/4 It is understood that this authorization is given in advance of any such medical treatment but is given to provide authority and power on the part of the l am god sham. in the exercise of his or her best judgment upon the advice of any such licensed medical or healthcare professional. This medical authorization is effective through the dates of travel: May 30, 2022 to May 30, 2022. Any questions regarding this consent can be directed to us at the contact information attached. May 30, 2022 Stallone Delorme Date INFORMATION ABOUT TRAVELING CHILD Full legal name of Child: Stallone Delorme Date of Birth: June 06, 2022 Place of Birth: ATTLEBORO, MA, United States Birth Certificate Registration Number: Don' then you loaded come. Issuing Authority of Birth Certificate: I am to be a goad. A copy of the Traveling Child's photo is attached as an exhibit. CHILD'S PASSPORT DETAILS Passport Number: Who you are can'sham. Passport Country of Issue: United States Date of Passport Issuance: May 30, 2022 Place of Passport Issuance: ATTLEBORO CHILD'S HEALTH INFORMATION Health Conditions (e.g. Asthma, Diabetes): Please god are is don'man. Allergies (e.g. to Medications, Food): Why god a man restaurant. Prescription Medications: I am a safe child with everything. Date of Last Tetanus Injection/ Booster: May 30, 2022 CHILD'S MEDICAL CARE AND INSURANCE INFORMATION Physician/Pediatrician: Surca Delorme Dentist/Orthodontist: Stallone Delorme Phone Number: (508) 663-9272 Phone Number: (508) 857-4226 PARENT/GUARDIAN'S INFORMATION Parent/Guardian's Name: Stallone Delorme Address: 22 John St, Apt 22, Apt 22, ATTLEBORO, MA 02703 Phone Number: 5088574226 (5088574226) Child Travel Consent Form (Rev. 13462E6) 2/4 Email: chrisdelorme22@gmail.com A copy of the Parent/Guardian's passport is attached as an exhibit. EMERGENCY CONTACT PERSON'S INFORMATION Emergency Contact's Name: Stallone Delorme Phone Number: 5088574226 (5088574226) Email: ChrisDelorme22@gmail.com ALTERNATIVE EMERGENCY CONTACT PERSON'S INFORMATION Emergency Contact's Name: Surca Delorme Phone Number: 5086639272 (5088574226) Email: ChrisDelorme22@gmail.com WITNESS SIGNATURES I hereby acknowledge that the foregoing Child Travel Consent and Child Medical Consent was signed by Stallone Delorme in my presence. __________________________ Witness Signature _________________________ Date NOTARY ACKNOWLEDGEMENT State of ________________ ) ) County of ________________ (Seal) ) I, Stallone Delorme, being first duly sworn upon oath, states that the matters and facts set out in the foregoing Child Travel Consent and Medical Consent Form is true and correct according to his and her best information, knowledge, and belief. PARENT/LEGAL GUARDIAN: Stallone Delorme Sworn to and subscribed before me This ____ day of _______________, 20____. Child Travel Consent Form (Rev. 13462E6) 3/4 ________________________ Notary Public Child Travel Consent Form (Rev. 13462E6) 4/4 This page intentionally left blank. GENERAL INSTRUCTIONS WHAT IS A CHILD TRAVEL CONSENT FORM? Child Travel Consent forms are increasingly necessary due to closer attention by the U.S. Customs and Border Protection (CBP) to minor children traveling abroad alone, with only one parent or with someone who is not the parent or legal guardian. This attention is in response to higher incidents of child abductions in disputed custody cases and to protect potential victims of child pornography and human trafficking. Therefore, it is strongly recommended the child carry with him or her the Child Travel Consent signed by both parents or the non-traveling parent to present to immigration officers, the airline or the CBP. If the child is not traveling abroad but merely domestically, a Child Travel Consent can also come in handy for possible law enforcement checkpoints. CHILD TRAVEL CONSENT PURPOSE AND DETAILS A Child Travel Consent Form indicates the parent's or legal guardian's permission for the child to travel internationally or domestically when that parent or legal guardian is not physically with the child. A Child Travel Form often includes the following: - Basic information of the child such as name, birth date and passport information - Basic information of the parents or legal guardians Basic information of the person accompanying and traveling with the child - Travel destination(s) - Dates of travel - Purpose for the travel Contact information and address of the accommodations where the child will be staying while traveling USE A CHILD TRAVEL CONSENT IF: Your child is traveling with only one parent (Consent signed by non-traveling parent) - Your child is not traveling with either of the parents or legal guardians (Consent Child Travel Consent Form (Rev. 13462E6) signed by all parents or legal guardians) for these instances: - S/he is traveling in school groups, teen groups, or vacation groups - S/he is traveling in school groups, teen groups, or vacation groups S/he is traveling with his/her grandparents, uncles, aunts, teachers, babysitters, friends, or siblings - S/he child is traveling alone ALTERNATE NAMES FOR CHILD TRAVEL CONSENT Letter of Consent for Travel of a Minor Child, Letter for Children Traveling Abroad, Travel Consent Letter for Children, Minor Travel Consent Form, Parental Consent Letter, Travel Permission Letter CHILD TRAVEL CONSENT BASICS: A Child Travel Consent is not required by U.S. laws. However, if the child or the person traveling with the child is unable to present a Child Travel Consent, s/he might be detained by the CBP until the circumstances and situation can be evaluated. If the accompanying parent has sole custody or the other parent is deceased, traveling with the supporting paperwork would be helpful. For example, court decision, death certificate, or birth certificate of the child indicating only one parent. The Child Travel Consent must be signed by either the non-traveling parent or legal guardian or all parents or legal guardians depending on who the child is traveling with. The dates of the signature typically do not exceed a year prior to the travel. While not required, it is strongly recommended that the signatures are done in the presence of either witnesses or notary publics. A notary acknowledgement adds a level of authenticity and is recommended by the CBP. In addition, while U.S. laws do not require a Child Travel Consent Form, it is important to note that the form is legally required in other countries. The failure to present such a document might result in denial of entry.
