Kentucky Parent/Guardian Consent Form

In accordance with 803 KAR 1:100, Section 3(2)(a) of the Kentucky Child Labor Law (Employment of Minors 16 or 17 years of Age), permission is hereby granted for the employment of:

Full Name of Minor(Required)

Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Date of Birth(Required)

Social Security Number(Required)

To work in excess of thirty (30) hours in any one work week, not to exceed forty (40) hours in any one work week when school is in session, at the following place of business:

Name of Business(Required)

Address at Which Minor will be Employed(Required)

Street Address Address Line 2 City State ZIP Code

Signature of Parent/Guardian(Required)

Today's Date(Required)

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