Form LS563 "Parent/Guardian Emergency Contact Information, Authorization for Emergency Medical Treatment" - New York

What Is Form LS563?

This is a legal form that was released by the New York State Department of Labor - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2018;
  • The latest edition provided by the New York State Department of Labor;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form LS563 by clicking the link below or browse more documents and templates provided by the New York State Department of Labor.

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Download Form LS563 "Parent/Guardian Emergency Contact Information, Authorization for Emergency Medical Treatment" - New York

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Division of Labor Standards
Permit and Certificate Unit
Harriman State Office Campus
Building 12, Room 185B
Albany, New York 12240
www.labor.ny.gov
Parent/Guardian Emergency Contact Information, Authorization for Emergency
Medical Treatment, and Permission to Perform
A. Instructions for Employers
Obtain the following information from the parent/guardian for each child performer employed.
B. Instructions for Parents
Complete Part C and Part D.
Sign and date the form.
Provide this completed form to the employer.
C. Performer and Parent/Guardian Information
Child Performer Name
Child Performer Stage Name (if different)
Child Performer Age
Parent/Guardian Name
Parent/Guardian Address
D. Parent/Guardian Emergency Contact Information and Authorization
Emergency contact name and relationship to child
Emergency contact phone number(s)
Home
Work
Cell
Medical conditions affecting child’s health or safety (optional)
Allergies (optional)
Name of child’s physician
Physician’s phone number
Check if applicable
The employer has access to the above information (Part C) through (name of organization)
which is providing the group of performers to the employer.
I have granted permission for the employment of the above named child, and I hereby authorize the provision of
emergency medical treatment to be provided for this child if needed during such employment.
Parent/Guardian signature
Date
LS 563 (09/18)
Division of Labor Standards
Permit and Certificate Unit
Harriman State Office Campus
Building 12, Room 185B
Albany, New York 12240
www.labor.ny.gov
Parent/Guardian Emergency Contact Information, Authorization for Emergency
Medical Treatment, and Permission to Perform
A. Instructions for Employers
Obtain the following information from the parent/guardian for each child performer employed.
B. Instructions for Parents
Complete Part C and Part D.
Sign and date the form.
Provide this completed form to the employer.
C. Performer and Parent/Guardian Information
Child Performer Name
Child Performer Stage Name (if different)
Child Performer Age
Parent/Guardian Name
Parent/Guardian Address
D. Parent/Guardian Emergency Contact Information and Authorization
Emergency contact name and relationship to child
Emergency contact phone number(s)
Home
Work
Cell
Medical conditions affecting child’s health or safety (optional)
Allergies (optional)
Name of child’s physician
Physician’s phone number
Check if applicable
The employer has access to the above information (Part C) through (name of organization)
which is providing the group of performers to the employer.
I have granted permission for the employment of the above named child, and I hereby authorize the provision of
emergency medical treatment to be provided for this child if needed during such employment.
Parent/Guardian signature
Date
LS 563 (09/18)