Consent Form for Domestic Travel Without Supervision

I declare that I am the parent / legal guardian of the student named below:
Student Name(Required)
E.g. BE12345
Date of Birth(Required)
The student has my consent to travel unaccompanied within the stated country of study, between the locations noted, using public transport.
Airport / port / station of entry
Host tutor's address
Parent / Guardian Name(Required)
Parent / Guardian Address(Required)