Company Name

First Name *

Last Name *

Email *

Phone 1 *

How many parents or legal guardians does the child have? * One parent or legal guardian Two parents or legal guardians Other (court-appointed or foster guardian)

Parent or Legal Guardian #1 – Full Name

Parent or Legal Guardian #1 – Relationship to Child * Parent Legal guardian Foster parent

Parent or Legal Guardian #1 – Phone Number *

Parent or Legal Guardian #1 – Email Address *

Parent or Legal Guardian #2 – Full Name

Parent or Legal Guardian #2 – Relationship to Child Parent Legal guardian Foster parent

Parent or Legal Guardian #2 – Phone Number

Parent or Legal Guardian #2 – Email Address

Will a parent or legal guardian be traveling with the child? * Yes No

Which parent or legal guardian will be traveling with the child? *

If no parent or legal guardian is traveling, who will the child be traveling with? * Another adult family member A designated adult chaperone An organized group (school, church, etc.) Not Applicable (traveling with parent or guardian)

Name of Adult or Group Traveling With the Child

Relationship of Adult to Child or Role in Group

Phone Number of Traveling Adult or Group Leader

Email Address of Traveling Adult or Group Leader

During travel, who will be primarily responsible for the child? * Traveling parent(s) or legal guardian(s) Named adult chaperone Group leader / organization

Have all parents or legal guardians given permission for this travel? * Yes No

Enter any additional information below: