Summer Youth Parent or Guardian Consent Form

Division of Industrial Compliance & Labor

Bureau of Labor and Worker Safety 6606 Tussing Road, PO Box 4009 Reynoldsburg, OH 43068-9009 Phone 614-644-2450 I Fax 614-728-8639 www.com.ohio.gov An Equal Opportunity Employer and Service Provider

Michael DeWine, Governor David Goodman, Director

PARENT OR GUARDIAN CONSENT FORM

First*

Last*

Middle Initial

Proof of Age (Minor must present a copy of proof of age that can be kept with personnel records). Type of Document*

Address of Minor

Street*

City, State*

ZIP*

Date of Birth*

Date

Age*

School District in Which Minor Lives*

School Minor Attends*

Name of Parent or Guardian*

Relationship to Minor*

Address of Parent of Guardian*

Phone*

Street

City, State

ZIP

I hereby certify that to the best of my knowledge and belief, the above statements are true and that the minor named above may work with my approval. Signature of Parent or Guardian Signature

Date

Minors aged sixteen or seventeen who are to be employed during summer vacation months after the last day of the school term in the spring and before the first day of the school term in the fall, in nonagricultural and nonhazardous employment as defined by the "Fair Labor Standards Act of 1938", 52 Stat. 1060.29 U.S.C.A. 201, and similar state statutes, or in other employment not prohibited to minors age sixteen or seventeen by law, shall not be required to provide an age and schooling certificate as a condition of employment. In order to be hired for employment during summer vacation months, such minors shall provide the employer with the following:

(1) Evidence of proof of age in the same manner as proof of age is provided the superintendent of schools under division C of section 3331.02 of the Revised Code.

(2) A statement signed by the minor's parent or guardian consenting to the proposed employment during the summer vacation months. For the purpose of this section, in the absence of a parent or guardian a person over eighteen years of age with whom the minor resides may sign such statement.

The employer shall retain a copy of the proof of age and the statement of consent with the minors employment records.