DLSE- 277 (Rev. 03/19) ** All areas must state SATISFACTORY for issuance of permit ** There is no fee. English ** Any alterations or falsifications may void this application ** Page 1 of 2 This form NOT VALID Online THIS IS NOT A PERMIT STATE OF CALIFORNIA NEW (never applied before) RENEW Division of Labor Standards Enforcement Permit No. APPLICATION FOR PERMISSION TO WORK IN THE ENTERTAINMENT INDUSTRY PROCEDURES FOR OBTAINING WORK PERMIT 226 NEW AND RENEWAL 1. Parent/Guardian must complete the information required below. Signature required. 2. School authorities must complete the 223School Record224 section below for minors in grades 1 thru 12 in original ink. No copies permitted. 3. For minors 15 days through kindergarten, please attach a photo copy of minor222s birth certificate. See reverse side for other documents that may be accepted. 4. Mail or present the completed application to any Labor Commissioner222s office for issuance of your work permit. Work permits will be issued and mailed to you. Van Nuys offers same-day processing. 5. Please provide a preaddressed, stamped envelope so the permit can be mailed back to you. Name of Child Professi onal Name (if applicable) AKA: Permanen t Address Number Street City State Zip Code Home Phone Number Mobile Phone Number Email Address Grade Level School Attending Date of Birth Age Height 221 223 ft. in. Weight lbs. Hair Color Eye Color Gender 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. By submitting personal information about yourself and your minor child to DLSE in order to obtain an entertainment work permit for your child, you consent to DLSE222s use of that personal information for purposes authorized by Labor Code 247 1308.5 and 1308.10, which provide for the issuance of such permits. Note that DLSE222s use of such personal information includes the disclosure of information about you and your minor child to third parties who want to verify a work permit. Name of Parent or Guardian (print or type) Signature X SCHOOL RECORD TO BE COMPLETED BY SCHOOL AUTHORITIES ONLY: Circle 223SATISFACTORY224 or 223UNSATISFACTORY224 for each category. Attendance SATISFACTORY / UNSATISFACTORY Academics (Grades) SATISFACTORY / UNSATISFACTORY Health 226 Please indicate if the minor requires medical approval to obtain a permit SATISFACTORY / NEED S MEDICAL APPROVAL I CERTIFY THAT THE ABOVE - NAMED MINOR : Meets the school district222s requirements with respect to age, school record, attendance and health. Does not meet the district222s requirements and permit should not be issued. [School Seal, Stamp, Address Stamp OR Letter on Signed & Dated Letterhead] REQUIRED Authorized School Official, Signature and Title X Date Signed School A ddress School Phone Number HEALTH RECORD Complete this Section if instructed to do so or if infant is under One Month of Age Na me 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 check) HE / SHE IS / IS NOT physically fit to be employed on any motion picture set or location. 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 X M.D. Date Signed *PLEASE USE DOCTOR222S OFFICE STAMP ON APPLICATION TO ENSURE AUTHENTICITY.* American LegalNet, Inc. www.FormsWorkFlow.com DLSE- 277 (Rev. 02/19) DEPARTMENT OF INDUSTRIAL RELATIONS English Division of Labor Standards Enforcement Application for Permission to Work in Entertainment Industry Page 2 of 2 Information covering California222s child labor laws applicable to the entertainment industry can be found at http://www.dir.ca.gov/dlse/DLSE-CL.htm . REQUIREMENTS FOR NON-SCHOOL AGE CHILDREN (15 days through kindergarten) A PHOTO COPY OF ONE OF THE FOLLOWING: 1.) Certified Birth Certificate 2.) Baptismal Certificate 3.) Official letter from hospital where born 4.) Passport * 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 is physically able to endure the stresses of a motion picture set or location. REQUIREMENTS FOR SCHOOL AGE CHILDREN (Grades 1 through 12) PUBLIC / PRIVATE SCHOOL, ON-LINE and VIRTUAL ACADEMY: 225 When school is IN session, the application must be completed and dated during the current school session by an authorized school official. 225 When school is NOT in session (i.e., school break, vacations, holidays), either the minor222s recent report card or letter from the school principal on school letterhead indicating that the minor is 223satisfactory224 in all academic subjects, health and attendance is required. HOMESCHOOL (ON-LINE and VIRTUAL ACADEMY see above): 225 If minor is homeschooled, the application must be completed by the parent/guardian and attached to either a current private school affidavit, or written verification indicating that the minor is 223satisfactory224 in all academic subjects, health and attendance from either the local school district, county office of education or state board of education where the minor lives. ADDITIONAL REQUIREMENTS FOR MINORS BETWEEN 14 AND 17 YEARS OF AGE AND THE PARENT OR LEGAL GUARDIAN 225 Applicants for Entertainment Work Permits for minors between the ages of 14 and 17 years of age (parent/legal guardian as well as the age-eligible minor) must provide satisfactory proof of sexual harassment prevention training before obtaining a minor222s Entertainment Work Permit. 225 Training Requirements: The sexual harassment prevention training must at a m355nimum include the components specified in the Department of Fair Employment and Housing222s form, DFEH Form 185. The training must be administered by a third-party vendor and may be provided electronically or on site, in a language the participants understand. 225 Options for 13-year-old minors turning 14: Applicants for Entertainment Work Permits for 13-year-old minors who will reach their 14th birthday during the six-month permitting period have the following options: 1. Apply for a permit which will expire on the minor222s 14th birthday 2. The Labor Commissioner will issue permits to minors at least 13 years and six months of age, who provide satisfactory proof of sexual harassment prevention training as an age-eligible minor. INFORMATION PRACTICES ACT NOTICE (California Civil Code Section 1798.17) 1. The information on this application is being requested by the Department of Industrial Relations, Division of Labor Standards Enforcement. 2. The information in this application is collected and maintained pursuant to California Labor Code sections 1308.5, 1308.10 and Title 8 California Code of Regulations section 11753. 3. If you fail to provide all or any part of the information requested in this application, the Labor Commissioner may deny issuance / renewal of an Entertainment Work Permit for minors under 18 years of age. 4. The principal purposes within the Division of Labor Standards Enforcement for which the information on this application will be used are: (1) administration of the registration for the employment of minors in the entertainment industry, and (2) enforcement of the California child labor laws. 5. The following are known or foreseeable disclosures of the information contained herein which may be made pursuant to subdivision (e) or (f) of Section 1798.24 of the California Civil Code by the Division of Labor Standards Enforcement. Response to a request under the California Public Records Act. 6. You have the right to access records containing your personal information that are maintained by the Division of Labor Standards Enforcement. To make a request to access such records, plea