Consent Form for Minors
This Consent Form parts A and B must be completed by the test taker and the parent / guardian before the minor can take the test.
A minor cannot complete test day check procedures without a signed copy of this form.
This form must be brought and presented to the administrator on test day.
Parents / Guardians seeking a chaperone opt out under section 2. Provisions below must submit this form to the Test Centre at least 7 calendar days before test date. (At the discretion of the test centre, opt-out forms may be accepted within 7 days of test date.)
This form applies to all IELTS Speaking interviews. It also applies to special access arrangements for Writing, Reading or Listening when a test taker alone with a helper.
A chaperone must be assigned in all cases except when a waiver is granted. See section 2. regarding waivers.
Read sections 1. – 3. Complete parts A and B and submit the form to your Test Centre at least 7 days before the test date.
1. The test centre will provide a chaperone as required. Apart from the examiner or special access facilitator, only the chaperone will be allowed in the speaking room with the minor.
2. A parent/legal guardian who does not want the test taker to be accompanied by a chaperone on test day, can request a waiver if…
• the test taker is at least 15 years of age on the test date.
• the parent/guardian contacts the test centre in writing at least 7 calendar days before test date with A and B of this consent form completed.
3. Test Centre duty of care regarding the minor ends when the minor is returned to a responsible legal guardian after the test, or, in case a responsible legal guardian is absent, returned to the publicly accessible areas of the test location.
A – For completion by Parent/Legal Guardian
I have read, understood, and accept the conditions on this form.
Full name (Parent or Legal Guardian)
Signature (Parent/ Legal Guardian)
Signed:
Date: September 30th, 2025
Tick one box only.
I consent for the test centre to arrange a chaperone for the test taker named in part B.
The test taker meets the conditions in section 2. and I do not wish the test centre to arrange a chaperone for the test taker named in part B.
Mobile number +62 811 19 2012
B - For completion by the IELTS test taker
Full name (Test Taker)
Signature (Test Taker)
Signed:
Date:
Age on test day 17 years and 4 months
ARDANTYA SYAHREZA
ARIELLO MUHAMMAD SYAHREZA