New York Child Travel Consent Form: Minor Travel Consent with Person in Parental Relation Designation (GOL § 5-1551)

Child Travel Consent Form (New York)

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 or passport card number: [Number] · Issuing country: [Country] · Expires: [Date]
Home address: [Street address], [City], New York [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], index or docket no. [number], [court and 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], address [address], 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] · Purpose of the trip: [Purpose]
Departure date: [Date] · Return date: [Date]

Date	From	To	Carrier, flight, crossing 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. A photocopy of each signing parent’s passport or other photo ID is attached.

6. Designation of Person in Parental Relation (General Obligations Law §§ 5-1551, 5-1552)

I/We, [name(s) of parent(s)], designate [companion’s name] as a person in parental relation to [child’s name], born [date of birth], for the purposes of consenting to medical, dental, health and hospital services and immunization for the child. The designation begins on [date or event] and ends on [date, no more than 12 months later], unless I/we revoke it earlier in writing.

Parent: address [Address] · phone [Phone]
Designee: address [Address] · phone [Phone]

There is no prior order of any court in any jurisdiction currently in effect prohibiting me/us from making this designation.

Consent of designee: I, [companion’s name], consent to this designation. Signature: ____________________ Date: __________

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 (New York)

State of New York )
) ss.:
County of ____________ )

On the [day] day of [month] in the year [year] before me, the undersigned, personally appeared [name(s)], personally known to me or proved to me on the basis of satisfactory evidence to be the individual(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 capacity(ies), and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument.

___________________________ (Signature and office of individual taking acknowledgment)

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

Documents to Carry

• The child’s passport, passport card or other travel document the route requires, and a copy of the birth certificate
• This signed and notarized consent, with a photocopy of each signing parent’s passport or 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. A designation under GOL § 5-1551 is not valid if a court order prohibits it, and where both parents must agree on health decisions, both must sign.

• Notarize it. A designation of a person in parental relation for more than 30 days must be notarized and include the designee’s written consent (GOL § 5-1552); for international travel, notarize the whole form anyway.

• Apostille, if asked. County clerk certification of the notary comes first, then the Department of State.

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