California Child Travel Consent Form: Notarized Minor Travel Consent with Medical Authorization (Fam. Code § 6910)

Child Travel Consent Form (California)

Consent of Parents or Legal Guardians for a Minor to Travel

1. Child

Full legal name: [Name]
Date of birth: [Date] · Place of birth: [City, state, country]
Passport number: [Number] · Issuing country: [Country] · Expires: [Date]
Home address: [Street address], [City], California [ZIP]

2. Parents or Legal Guardians

Parent or guardian 1: [Name] · Address: [Address] · Phone: [Phone] · E-mail: [E-mail] · ID: [Type and number]

Parent or guardian 2: [Name] · Address: [Address] · Phone: [Phone] · E-mail: [E-mail] · ID: [Type and number]

☐ Only one parent or guardian signs because (check one): ☐ I have sole legal custody under the order dated [date] in case no. [number], Superior Court of California, County of [county] (copy attached) ☐ the other parent is deceased (death certificate attached) ☐ only one parent is named on the birth certificate ☐ other: [explain]

3. Travel Companion

☐ The child travels with one parent: [Name].
☐ The child travels with another adult: [Name], [relationship to the child], date of birth [date], passport or ID no. [number], phone [phone].
☐ The child travels with a group: [school, team or organization], led by [name and phone].
☐ The child travels alone as an unaccompanied minor and will be met at [place] by [name, phone].

4. Trip

Destination(s): [Cities and countries]
Departure date: [Date] · Return date: [Date]

Date	From	To	Carrier, flight or route	Staying at (address, phone)
[Date]	[City]	[City]	[Details]	[Details]
[Date]	[City]	[City]	[Details]	[Details]

5. Consent

I/We, the undersigned parent(s) or legal guardian(s) of the child named above, consent to the child traveling to the destination(s) listed above from [date] to [date] with the travel companion named in Section 3. I/We acknowledge that my/our son/daughter is traveling out of the country with [companion’s name], who has my/our permission to do so. This consent covers the trip described above only and may be revoked in writing at any time.

6. Authorization to Consent to Medical and Dental Care (California Family Code § 6910)

The child has been entrusted to the care of [companion’s name] for the trip described above. Under California Family Code § 6910, I/we authorize [companion’s name] to consent to ☐ medical care ☐ dental care for the child while the child is in [his/her/their] care. I/We ask to be contacted first whenever possible.

Allergies: [List] · Medications and doses: [List] · Conditions: [List]
Health insurance: [Insurer, member number, phone] · Child’s doctor: [Name, phone]

7. Contacts During the Trip

Parent or guardian 1: [Phone] · Parent or guardian 2: [Phone] · Emergency contact: [Name, relationship, phone]

8. Signatures

Parent or guardian 1: ___________________________ Printed name: [Name] Date: __________

Parent or guardian 2: ___________________________ Printed name: [Name] Date: __________

Certificate of Acknowledgment (California Civil Code § 1189)

A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document.

State of California
County of ____________

On [date] before me, [here insert name and title of the officer], personally appeared [name(s) of signer(s)], who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument.

I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct.

WITNESS my hand and official seal.

Signature ___________________________ (Seal)

[If the parents sign at different times or places, attach a separate certificate for each signer.]

Documents to Carry

• The child’s passport or other travel document the route requires, and a copy of the birth certificate
• This signed and notarized consent, with a copy of each signing parent’s photo ID
• A copy of any custody order or death certificate referred to in Section 2
• For a child leaving Mexico without a parent: the SAM form or other authorization Mexican immigration requires

Before You Travel (Delete This Section)

• Check your custody order first. Travel restrictions under Family Code § 3048 control over this form, and taking a child in violation of custody or visitation rights can be a crime (Penal Code § 278.5).

• Notarize it with the California certificate above, and ask the destination’s embassy or consulate whether it needs an apostille or a translation.

• Passports are separate. For a child under 16, the non-applying parent’s consent goes on Form DS-3053 (22 CFR 51.28).

• Longer stays. If the child will live with a relative or other caregiver, the caregiver can use a Caregiver’s Authorization Affidavit (Family Code § 6550) for school enrollment and, for a relative, medical and dental care.