"Parent/Guardian Emergency Contact Information, Authorization for Emergency Medical Treatment, and Permission to Perform" - Georgia (United States)

Parent/Guardian Emergency Contact Information, Authorization for Emergency Medical Treatment, and Permission to Perform is a legal document that was released by the Georgia Department of Labor - a government authority operating within Georgia (United States).

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Child Labor Unit
Georgia Department of Labor
148 Andrew Young International Blvd., N.E.
Suite 700
Atlanta, Georgia 30303-1751
dol.georgia.gov
Parent/Guardian Emergency Contact Information, Authorization for Emergency
Medical Treatment, and Permission to Perform
A. Instructions for Employers
Obtain completed form from the parent/guardian of each Minor employed prior to first call [300-7-1-.03 (7)(a)].
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
Minor Performer Name
Minor Performer Stage Name (if different)
Minor Performer Age
Parent/Guardian Name
Parent/Guardian Address
D. Parent/Guardian Emergency Contact Information and Authorization
Emergency contact name and relationship to minor
Emergency contact phone number(s)
Home
Work
Cell
Medical conditions affecting minor’s health or safety (optional)
Allergies (optional)
Name of minor’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 minor, and hereby authorize the provision of
emergency medical treatment to be provided for this minor if needed during such employment.
Parent/Guardian Signature
Date
Clear
Print
Child Labor Unit
Georgia Department of Labor
148 Andrew Young International Blvd., N.E.
Suite 700
Atlanta, Georgia 30303-1751
dol.georgia.gov
Parent/Guardian Emergency Contact Information, Authorization for Emergency
Medical Treatment, and Permission to Perform
A. Instructions for Employers
Obtain completed form from the parent/guardian of each Minor employed prior to first call [300-7-1-.03 (7)(a)].
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
Minor Performer Name
Minor Performer Stage Name (if different)
Minor Performer Age
Parent/Guardian Name
Parent/Guardian Address
D. Parent/Guardian Emergency Contact Information and Authorization
Emergency contact name and relationship to minor
Emergency contact phone number(s)
Home
Work
Cell
Medical conditions affecting minor’s health or safety (optional)
Allergies (optional)
Name of minor’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 minor, and hereby authorize the provision of
emergency medical treatment to be provided for this minor if needed during such employment.
Parent/Guardian Signature
Date
Clear
Print