I'm not an attorney, but a paralegal that works for a family law attorney. This is the form I use:
I, ________________________, hereby give my permission for __________________ to take my son/daughter, ____________________ (fill in name or names), Date of Birth:____________________ out of the country from ________________________ to _______________ (fill in dates) on __________________________ (name of ship) stopping in ports ______________________________ (fill in name of ports and dates).
STATE OF ___________________
COUNTY OF _________________
On this the _______ day of _______________, 2005, before me, the undersigned officer, personally appeared the above-named ________________, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument and acknowledged that he/she/they signed the foregoing for the purpose therein contained.
Notary Public/Justice of the Peace
My Commission Expires: