State of Tennessee Rev. 133EEF3 CHILD TRAVEL CONSENT FORM We, Celina Perez Herrera and Jose de Jesus Conchas, are the parents/legal guardians of Samuel Conchas Perez, born September 15, 2008. We acknowledge that our child is traveling internationally and has our consent and permission to travel with __________, our child’s __________. TRIP DETAILS CHILD’S NAME: Samuel Conchas Perez ACCOMPANYING PERSON: __________ TRAVEL DESTINATION: TRAVEL DATES: June 28, 2023 to July 12, 2023 PURPOSE: - Vacation - Visiting relatives ADDRESS AT DESTINATION: __________ __________, __________, __________, __________ __________ __________ RIGHT TO WITHDRAW TRAVEL CONSENT If at any time, the travel destination becomes under a Level Four Travel Advisory, as determined by the Center for Disease Control or under a Level Three (or Higher) Travel Advisory by Homeland Security), we have the right to withdraw our travel consent immediately upon written notification of the same. MEDICAL CONSENT We grant our authorization and consent for __________ to administer general first aid treatment for any minor injuries or illnesses experienced by the Minor Child. If the injury or illness is life threatening or in need of emergency treatment, we authorize __________ to summon any and all professional emergency personnel to attend, transport, and treat the Minor Child and to issue consent for any X-Ray, anesthetic, blood transfusion medication, or other medical diagnosis, treatment, or hospital care deemed advisable by, and to be rendered under the general supervision of, any licenses physician, surgeon, dentist, hospital, or other medical professional or institution duly licenses to practice in the state or country in which such treatment is to occur. We agree to assume financial responsibility for all expenses of such care. 1/4 It is understood that this authorization is given in advance of any such medical treatment but is given to provide authority and power on the part of the __________ in the exercise of his or her best judgment upon the advice of any such licensed medical or healthcare professional. This medical authorization is effective through the dates of travel: June 28, 2023 to July 12, 2023. Any questions regarding this consent can be directed to us at the contact information attached. __________ Celina Perez Herrera Date __________ Jose de Jesus Conchas Date Information about Traveling Child Full Legal Name of Child: Samuel Conchas Perez Date of Birth: September 15, 2008 Place of Birth: Jackson, Tennessee, USA Child’s Passport Details Passport Number: __________ Place of Passport Issuance: __________ Passport Country of Issue: __________ Date of Passport Issuance: April 28, 2022 Child’s Health Information Health Conditions (e.g. Asthma, Diabetes): __________ Allergies (e.g. to Medications, Food): __________ Prescription Medications: __________ Date of Last Tetanus Injection/Booster: __________ Child’s Medical Care and Insurance Information 2/4 Physician/Pediatrician: __________ Dentist/Orthodontist: __________ Preferred Medical Facility: __________ Insurance Company: __________ Policy/Group Number: __________ Policy Holder: __________ Phone Number: Phone Number: __________ __________ Parent/Guardian’s Information Parent/Guardian's Name: Celina Perez Herrera Address: 119 S Poplar St, Camden , TN 38320 Phone Number: 7312202313 (__________) Email: __________ Parent/Guardian's Name: Jose de Jesus Conchas Address: 119 S Poplar St, Camden , TN 38320 Phone Number: 7312205213 (__________) Email: __________ Emergency Contact Person’s Information Emergency Contact's Name: __________ Email: __________ Alternative Emergency Contact Person’s Information Emergency Contact's Name: __________ Email: __________ NOTARY ACKNOWLEDGEMENT State of ________________ ) ) County of ________________ (Seal) ) We, Celina Perez Herrera and Jose de Jesus Conchas being first duly sworn upon oath, states that the matters and facts set out in the foregoing Child Travel Consent is true and correct according to his and her best information, knowledge, and belief. PARENT/LEGAL GUARDIAN: PARENT/LEGAL GUARDIAN: 3/4 Celina Perez Herrera Sworn to and subscribed before me This ____ day of ____________, 20____. Jose de Jesus Conchas Sworn to and subscribed before me This ____ day of ____________, 20____. _________________________________________ Notary Public 4/4