Florida Child Travel Consent Form: Minor Travel Consent with Health Care Surrogate Designation (Fla. Stat. § 765.2035)

Child Travel Consent Form (Florida)

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], Florida [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): ☐ the parenting plan or order dated [date] in case no. [number], [county] County Circuit Court, gives me sole parental responsibility or permits me to consent alone (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, countries or cruise itinerary]
Departure date: [Date] · Return date: [Date]

Date	From	To	Carrier, flight, ship or route	Staying at (address, phone)
[Date]	[City or port]	[City or port]	[Details]	[Details]
[Date]	[City or port]	[City or port]	[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. Designation of Health Care Surrogate for a Minor (Florida Statutes § 765.2035)

I/We, [name(s) of parent(s) or legal guardian(s)], designate [companion’s name], a competent adult, of [address and phone], as health care surrogate to make health care decisions for [child’s name], born [date of birth], if I/we cannot be reached. ☐ Alternate surrogate: [name, address, phone].

☐ The surrogate may consent to medically necessary surgery and general anesthesia. ☐ These services are excluded.
☐ The surrogate may also consent to mental health treatment. ☐ Mental health treatment is excluded.

This designation ends on [date, the end of the trip] unless revoked earlier. An exact copy has been given to the surrogate.

Signature of parent or guardian: ____________________ Date: __________

Witness 1 (adult, not the surrogate): ____________________ Printed name: [Name]
Witness 2 (adult, not the surrogate): ____________________ Printed name: [Name]

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: __________

Acknowledgment (Florida Statutes § 695.25)

STATE OF FLORIDA
COUNTY OF ____________

The foregoing instrument was acknowledged before me by means of ☐ physical presence or ☐ online notarization, this [date] by [name of person acknowledging], who is personally known to me or who has produced [type of identification] as identification.

___________________________ (Signature of person taking acknowledgment)
[Name typed, printed or stamped]
[Title or rank]
[Serial number, if any]

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

Documents to Carry

• The child’s passport or other travel document the route or cruise line 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 parenting plan, court 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 parenting plan first. Its travel and passport provisions control over this form, and taking a child from a lawful custodian can be a felony (§ 787.03).

• Witness the surrogate designation. Two adults who are not the surrogate must watch the parent sign Section 6, and the surrogate gets an exact copy (§ 765.2035).

• Notarize it for international travel and cruises, 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).