Airline Emergency Services Form

To:__________________________________  At Fax # ____________________________________

After Faxing, mail to: _______________________________________________________________

___________________________________________________________________________________________

 
Non Flying Spouse/Guardian Permission Affidavit for Minor Child to Travel

            I ___________________________ am the father/mother/guardian ________________________

 
 of ____________________________________________________________who is scheduled to fly on

 
Airline___________________________ Flight____________________ Date______________________

 
with _____________________________________ to_________________________________________.

 I am aware of the above and give my permission for the child to depart as described.

 Sign Name:__________________________________________________

 
Print Name:__________________________________________________

 State of New York

County of _____________________

Sworn to and subscribed before me this _________ day of ______________________, 20___

            Notary Public                                                                            Commission Expires

Signer produced ________________________________________________ as identification

 ID number ________________________________________________________________