Instructions for Travel Consent Form

If one legal parent is traveling by air or crossing a border with a minor child, this form should be
signed by the legal parent that is not traveling with the child.

If a minor child is traveling by air or crossing a border with someone other than either legal parent,
BOTH legal parents should sign this form.

If one or both legal parents are deceased, a certified death certificate should be attached to this
form. If one of the legal parent's whereabouts is unknown, a separate affidavit stating such is
suggested.

"Legal parents" includes individuals who are the legal guardians of the child.

Travel Consent Form

By signing below, I approve travel for my minor child as follows:

Name: Lillian Haviv Grygoryeva

Date of Birth: June 17, 2021
Place of Birth: Anchorage, AK
Passport Number: 682082964
Date of Issue: September 16, 2022
Place of Issuance: United States

The child will travel to the following location on the following dates:

Traveling to: Cancun, Mexico

From: November 22, 2022 to November 30, 2022

The following named adult will accompany my child:

With: Elana Habib

Relation: Mother
Passport Number: 682516871
Date of Issue: September 22, 2022
Place of Issuance: United States

In the event of an emergency, I can be reached at:

Address: 3404 W 84th Ave, Unit 1

Anchorage, Alaska 99502
Home Phone Number: 6233360748

This is a RocketLawyer.com document.

 Cell Phone Number: _________________
Work Phone Number: _________________

In addition, I authorize Elana Habib to consent to any necessary routine or emergency medical
treatment during the aforementioned trip.

Signature: ________________________________
Anton Grygoryev
Father

STATE OF ALASKA
COUNTY OF UNITED STATES

On ____________________, before me,____________________, personally

appeared,______________________________, who personally known to me or proved to me
on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the
within instrument and acknowledged to me that he/she executed the same in his/her authorized
capacity(ies), and that by his/her signature(s) on the instrument the person(s) or the entity upon
behalf of which the person(s) acted, executed the instrument.

Witness my hand and official seal

____________________________________
(notary signature)

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