Minor Work Waiver Form

Minor Work Waiver Form
Complete this form to provide the minor’s details, work assignment information, and the required waiver authorization for the minor work arrangement.
Minor and Guardian Details
Minor's Full Name
First NameMiddle NameLast Name
Minor's Date of Birth
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Minor's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Parent / Legal Guardian Full Name
First NameMiddle NameLast Name
Relationship to Minor
Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Guardian Email Address
example@example.com
Work Assignment Details
Employer/Company Name
Work Location Address
Street Address
Street Address Line 2
CityState / ProvincePostal / Zip Code
Role or Task Description
Intended Work Start Date
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Expected Work Schedule or Hours
Special Instructions or Restrictions
Waiver and Authorization
Guardian Signature
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