Illinois Child Travel Consent Form: Minor Travel Consent with Short-Term Guardian Appointment (755 ILCS 5/11-5.4)

Child Travel Consent Form (Illinois)

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], Illinois [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 allocation judgment or order dated [date] in case no. [number], Circuit Court of [county] County, gives me sole decision-making responsibility on this matter (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. Appointment of Short-Term Guardian for the Trip (755 ILCS 5/11-5.4)

[Complete only if the child travels without either parent.]

Date of this instrument: [Date]

I/We, [name(s) of appointing parent(s) or guardian], appoint [companion’s name], of [address and phone], as short-term guardian of [child’s name], born [date of birth]. The appointment takes effect on [date or event, for example the departure date] and ends on [date or event, for example the child’s return home], and in any case no later than 365 days after it takes effect. I/We may amend or revoke it at any time.

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

Signature of appointing parent or guardian: ____________________ Date: __________
Signature of the other parent (consenting): ____________________ Date: __________

Witness 1 (18 or older, not the short-term guardian): ____________________ Printed name: [Name]
Witness 2 (18 or older, not the short-term guardian): ____________________ Printed name: [Name]

Acceptance by short-term guardian: ____________________ Date: __________

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: __________

Notary Acknowledgment (5 ILCS 312/6-105)

State of Illinois
County of ____________

This instrument was acknowledged before me on [date] by [name/s of person/s].

___________________________ (Signature of Notary Public)
[Seal]

[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 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 allocation judgment, parenting plan 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 allocation judgment or parenting plan first. Its travel provisions control over this form, and removing a child in violation of a custody order is a felony (720 ILCS 5/10-5).

• Witness the short-term guardian appointment. Two adults who are not the guardian must watch the parent sign Section 6, the guardian signs too, and the other parent signs if living, reachable and able to care for the child (755 ILCS 5/11-5.4).

• Notarize it for international travel, 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).