Llc-12 - Application For Permit For Employment Of A Minor In Theatrical And Other Performances Page 2
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2_______________________________________
INFORMATION ABOUT:
NAME OF MINOR
(To be completed by the School District)
Note: For performances or rehearsals given during school vacations, the school district is not required to complete the following.
Name of school district where minor resides _______________________________________ Telephone (_____) -____________________
Address of school district ________________________________________________________________________________________
STREET
CITY
STATE
ZIP CODE
Grade completed in school __________________________________
Hours per week attending school _________________
If child is presently tutored instead of attending school, give name of tutor____________________________________________________
Address of tutor ______________________________________________________________________________________________
STREET
CITY
STATE
ZIP CODE
Is tutor a certified teacher?
Yes
No
Has the school of residence approved the subjects for tutoring?
Yes
No
SCHOOL OFFICIAL’S STATEMENT: (To be filled in when the performances or rehearsals require any absence from regular day school.)
To the best of my knowledge and belief, the performances and rehearsals outlined above will not interfere with the educational instruc-
tion or school progress of the pupil named on the front of this form.
_____________________________________________________
______________________________________________________
SIGNATURE OF PRINCIPAL OF SCHOOL ATTENDED
SIGNATURE OF SCHOOL OFFICIAL ISSUING EMPLOYMENT
CERTIFICATE IN DISTRICT WHERE PUPIL RESIDES
NAME OF SCHOOL DISTRICT OR JOINT SYSTEM
NAME OF SCHOOL
ADDRESS OF SCHOOL
INFORMATION ABOUT THE EMPLOYMENT
(To be completed by the Employer)
Name of production company _____________________________________________
Telephone (____) -____________________
Address of production company ________________________________________________________________________________
STREET
CITY
STATE
ZIP CODE
Name of production ___________________________________________________________________________________________
Type of production _________________________________ Type of performance of minor _________________________________
Date(s) of rehearsals __________________________________________________________________________________________
Date(s) of the performances ________________________________
No. of performances per day __________
Per week________
Maximum combined rehearsal and performance time per day _________________________ Per week _________________________
Hours at which minor reports for performances _____________________________________________________________________
Duration of time of minor’s performance __________________________________________________________________________
Where will performance be presented (theatre, club, etc.)?
Specify ____________________________________________________
Address ____________________________________________________________________________________________________
STREET
CITY
STATE
ZIP CODE
Will alcoholic beverages be dispensed to the patrons during the performance?
Yes
No
Will minor be paid for performing?
Yes
No
If Yes, give amount by week $______________ by performance $___________
Will there by any remuneration other then money?
Yes
No
If minor is performing away from his/her home community, who is responsible for Transportation? ____________________________
Meals and Lodging? ____________________________
Education? ______________________________
STATEMENT OF EMPLOYER: In applying for the Special Performance Permit, I certify that, to the best of my knowledge and belief, all
statements above are true and accurate.
SIGNATURE OF EMPLOYER
DATE
Note: If Special Performance Permit is to be mailed to someone other than the employer named, mail to:
Name_________________________________________________________________________________________________________________________
Address _____________________________________________________________________________________________________________________
STREET
CITY
STATE
ZIP CODE
LLC-12 REV 8-04 (Page 2)
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