Statutory authorization of the legal representative of a child for travelling

abroad accompanied by a non-parent

I the undersigned Mr / Ms * (name and surname) ..............................................................,

being the child´s father / mother / other * ............., exercising parental authority of this child,

born in (place) ............................ on (date) ............................................,

with permanent address ..............................................................................................,

identification number / passport number*..........................................................,

hereby authorize my son / daughter / other * ...................

(name and surname) ................................................................................,

born in (place) ............................ on (date) ............................................,

with permanent address..............................................................................................,

passport number ...................................................

to travel to (country) Italy

from 16.6.2023 to 19.6.2023 (dates)

in the company of Mr / Ms * (name and surname) Zuzana Eichler

being the child´s mother / father / grandparent / other * teacher,

born in (place) Nové Zámky on (date) 4.5.1979

with permanent address Žerotínova bašta 15, 940 56 Nové Zámky

identification number / passport number*MP897 809.

This authorization applies only for the above mentioned trip and is valid from 16.6.2023to
19.6.2023

In (place)………….. on (date) ……………. Signature:

…………………………..

Place for the notary or consular legalization of the delegating person´s signature.

Note:

The model of the statutory authorization above inducted is not a legally binding form, and each
state may have other requirements for its content and form. Therefore the requirements on the
statutory authorization have to be checked at the relevant authorities of the foreign destination
country.

* wrong word to be deleted