WORK PERMIT FORM copy

STATE OF CALIFORNIA
Division of Labor Standards Enforcement
THIS IS NOT A PERMIT
RENEWAL
NEW
APPLICATION FOR PERMISSION TO WORK IN THE ENTERTAINMENT INDUSTRY
PROCEDURES FOR OBTAINING WORK PERMIT
1. Complete the information required below.
2. School authorities must complete the "School Record" section below.
3. For minors 15 days through kindergarten, please attach a certified copy of the minor's birth certificate. See reverse side
for other documents that may be accepted.
4. Mail or present the completed application to any office of the Division of Labor Standards Enforcement for issuance of
your work permit. Work permits will be issued within 3 business days and mailed to you.
5. Please provide a preaddressed, stamped envelope.
Name of Child
Professional Name (if applicable)
Permanent Address
Number
Street
City
State
Home Phone Number
Zip Code
School Attending
Grade
Date of Birth
Age
Height
Weight
Hair Color
Gender
Eye Color
Male
Female
STATEMENT OF PARENT OR GUARDIAN: It is my desire that an Entertainment Work Permit be issued to the above named child. I will
read the rules governing such employment and will cooperate to the best of my ability in safeguarding his or her educational, moral and physical
interest. I hereby certify, under penalty of perjury, that the foregoing statements are true and correct.
Name of Parent or Guardian ( print or type)
Signature
Daytime Phone Number
SCHOOL RECORD
State whether “SATISFACTORY" or "UNSATISFACTORY" for each
Attendance
Scholarship (Grades)
Health
I CERTIFY THAT THE ABOVE-NAMED MINOR:
Meets the school district's requirements with respect to age, school record, attendance and health.
Does not meet the district’s requirements and permit should not be issued.
Authorized School Official
Date
School Address
School Phone Number
[School Seal]
HEALTH RECORD
Complete this Section if instructed to do so or if infant is under One Month of Age
Name of Doctor
Address
Phone Number
I certify that I am a licensed physician and surgeon who is Board Certified in pediatrics, and have carefully examined _______________________.
In my opinion, (please circle) he / she is / is not physically fit to be employed in the production of motion pictures and television. If less
than one month, infant is / is not at least 15 days old, was / was not carried to full term, and is / is not physically able to perform.
Signature
Remarks:
DLSE-277 (Rev. 12/03)
M. D.
Date
Information covering California's child labor laws applicable to the entertainment industry can be
found at www.dir.ca.gov/dlse/dlse.html
PROCEDURE FOR OBTAINING AN “ENTERTAINMENT PERMIT”
NEW
Obtain from any of the Division of Labor Standards offices.
Complete all requested information on the front of the application.
Please print and sign your name.
3.) School Record Information To be completely filled out by authorized school district official.
1.) Application Form
2.) Parent/Guardian
A PREADDRESSED, STAMPED ENVELOPE MUST ACCOMPANY THE APPLICATION
REQUIREMENTS FOR NON-SCHOOOL AGE CHILDREN
1.)
2.)
3.)
4.)
ONE OF THE FOLLOWING:
Certified Birth Certificate
Baptismal Certificate
Official letter from hospital where born
Passport
When school is IN session, the application must be completed and dated during the current school
session by an authorized school official.
When school is NOT in session, (i.e., school break, vacations, holidays), either the minor’s recent
report card or letter from the school principal on school letterhead indicating that the minor is
“satisfactory” in all academic subjects, health and attendance is required.
If a minor is from out of state, either the minor’s recent report card or letter from the school principal
on school letterhead indicating that the minor is “satisfactory” in all academic subjects, health and
attendance is required.
Entertainment permits that are issued based on report cards will be effective when school is not in
session. Please include a self addressed, stamped envelope so that the permit can be mailed to you.
*
Every infant under one month of age must have a certification from a licensed physician and
surgeon who is Board Certified in pediatrics certifying that the infant is at least 15 days old,
was carried to full term, and physically able to endure the stresses of a television or movie set.
RENEWAL
1.)
2.)
3.)
4.)
5.)
Complete application form (all questions).
Send a copy of the old permit with the application.
Enclose a self addressed, stamped envelope for return.
If school is not in session, see above instructions.
If school is in session, have school official complete and sign the “school record” section
of the application form.
THERE IS NO FEE
SOCIAL SECURITY NUMBER IS NOT REQUIRED
APPLICATION CANNOT BE PROCESSED VIA FAX
DEPARTMENT OF INDUSTRIAL RELATIONS
Division of Labor Standards Enforcement