Name of Child
Professional Name (if applicable)
Home Phone Number
Date of Birth
Name of Parent or Guardian ( print or type)
THIS IS NOT A PERMIT
STATE OF CALIFORNIA
Division of Labor Standards Enforcement
APPLICATION FOR PERMISSION TO WORK IN THE ENTERTAINMENT INDUSTRY
Number Street City State Zip Code
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.
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.
Signature Daytime Phone Number
Complete this Section if instructed to do so or if infant is under One Month of Age
State whether “SATISFACTORY" or "UNSATISFACTORY" for each
Authorized School Official
I CERTIFY THAT THE ABOVE-NAMED MINOR:
Does not meet the district’s requirements and permit should not be issued.
School Phone Number
I certify that I am a licensed