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intake


Consent To Travel Intake Form- enter the information below and submit the form. After you've completed the form but before clicking submit, you may want to print the form out.

Your Information:

Name:
Address:
Phone:

Names and Dates of Birth of Children:

, born the day of , ,
, born the day of , ,
, born the day of , ,

Travel Information

Travel Destination:

Who will accompany the children?

This (or these) person(s) will have your permission to authorize and sign for emergency medical treatment for our above named children, if it is required.


The dates for travel are from
the day of , to
the day of ,



Click "submit" and the Consent to Travel letter will be prepared by our office. You will be contacted in order to have the document notarized.