Travel Consent Form

Name *

First

Last

Parent/Guardian Name

First

Last

Please Specify Relationship to Traveler:

Mother, Grandfather, Nanny, etc.

Email *

Travel Information

Travel Destination

Destination Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date of Departure *

Date of Return *

Reason for Travel *

Traveler's Information

Date of Birth *

Current Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Does the traveler have any medical conditions? *

Please provide details of all medical conditions

Please provide details of medication that the traveler should carry

Are there any known allergies? *

Please provide details of all known allergies

Does the traveler carry an Epi-Pen or similar device?

Yes
No

Are there any specific dietary requirements not covered above? *

Please provide details of dietary requirements

If other, please describe below

Traveler's Passport Information

Only in the case of international travel (these fields are not mandatory)

Passport Number

Passport Expiry Date

Emergency Contact Information

Emergency Contact Name *

First

Last

Phone *

Email *

Consent

I agree that the above mentioned traveler may: *

Take part in the trip detailed above
Be given first aid or urgent medical treatment in any event

Signature *