PARENTAL ACKNOWLEDGEMENT
OF MINOR’S DUTIES AND HOURS
OF EMPLOYMENT
LLC-75 01-13
Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
(Must be completed for minors under 16 years of age)*
(This section to be completed by the employer.)
The undersigned parent or legal guardian of , age ,
(name of minor)
hereby acknowledges and understands that this minor’s employment with
, commencing , will consist of the following duties and hours:
(name of employer) (date)
(This section to be completed by the employer.)
Duties of minor (e.g., cashier, food service,
lifeguard, sales clerk, etc.)
(
□ additional sheet(s) attached)
Hours of work:
Sunday .m.- .m.
Monday .m.- .m.
Tuesday .m.- .m.
Wednesday .m.- .m.
Thursday .m.- .m.
Friday .m.- .m.
Saturday .m.- .m.
Other/additional hours (include explanation):
(To be signed by minor’s parent or legal guardian.)
I hereby acknowledge that I understand the above duties and hours to be worked by the above-named
minor for this employer and grant permission for this employment. This statement is made subject to the
provisions of 18 Pa. C.S. § 4904 (relating to unsworn falsications to authorities).
□ Parent of
(Printed name of parent or legal guardian)
□ Legal guardian
(Name of minor)
(Signature of parent or legal guardian) (Date)
* This form is required to be completed by the parent or legal guardian of a minor employee under 16 years of age pursuant to
Section 8(a)(2)(ii) of the Child Labor Act, and the original copy must be kept by the employer at the workplace along with other
records of the minor’s employment required by Section 8(d).
DEPARTMENT OF LABOR & INDUSTRY
BUREAU OF LABOR LAW COMPLIANCE
Applicants may be placed in work
experiences with duties that could include, but
are not limited to, standard office functions, career
exposure classroom activities andservice projects.
Philadelphia Youth Network , Inc.
Minimum hours are 120 to a max 240
07/05/2022
