Llc-12 - Application For Permit For Employment Of A Minor In Theatrical And Other Performances
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1
2APPLICATION FOR PERMIT FOR EMPLOYMENT OF A MINOR IN
THEATRICAL AND OTHER PERFORMANCES
For the employment of any minor under 18, in compliance with the Pennsylvania Child Labor Law, in theatrical productions,
musical recitals or concerts, entertainment acts, modeling, television, radio, motion picture making, or in other similar forms
of entertainment.
The application must be signed by the employer and the parent or guardian of the minor, and notarized. The application must
be received not less than two weeks prior to the performance and/or first rehearsal.
Return To:
Bureau of Labor Law Compliance
1301 Labor and Industry Building
Seventh and Forster Streets
Harrisburg, PA 17120-0019
Telephone: 717-787-4671 or
1-800-932-0665
FAX: 717-787-0517
INFORMATION ABOUT THE MINOR
(To be completed by Parent or Guardian)
Legal name of minor _______________________________________ Social Security No. ______________________
Permanent address ___________________________________________________________________________________
STREET
CITY
STATE
ZIP CODE
Telephone (____) - _________________________
Date of birth ______ /______ /______
MONTH
DAY
YEAR
Name of parent or guardian ______________________________________ Telephone (____) - __________________
Permanent address ___________________________________________________________________________________
STREET
CITY
STATE
ZIP CODE
Name of parent or representative who will accompany the minor to rehearsals or performances ______________________
__________________________________________________________________________________________________
Do the minor’s total earnings exceed $150.00 a week?
Yes
No
Does the minor have a booking agent?
Yes
No
If Yes, name of booking agent _________________________________________ Telephone (____) - ______________
Address of booking agent ______________________________________________________________________________
STREET
CITY
STATE
ZIP CODE
In applying for the Special Performance Permit, I certify that, to the best of my knowledge and
STATEMENT OF PARENT:
belief, all statements above are true and accurate.
____________________________________________________________________________________________
DATE
SIGNATURE OF PARENT OR GUARDIAN
____________________________________________________________________________________________
DATE
NOTARY’S SEAL AND SIGNATURE
Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
LLC-12 REV 8-04 (Page 1)
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF LABOR AND INDUSTRY
BUREAU OF LABOR LAW COMPLIANCE
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