Groveport Madison Schools District Service Center 4400 Marketing Place, Suite B Groveport, OH 43125 614-492-2520 www.gocruisers.org

WORK PERMIT INSTRUCTIONS AND APPLICATION

Students must attend Groveport Madison Schools (either as a resident or open enrollment student) to obtain a work permit from our school district. Ohio law states that all employed minors betweenthe ages of 14 and 18 must have a work permit on file with the school district they attend. Our district is required to process work permits through the Ohio Department of Commerce. A new work permit is required each time the student changes their place of employment. Once a student turn 18 years old, he/she no longer needs a work permit even though they are still a student.

PLEASE FOLLOW THESE STEPS:

1. COMPLETE BOTH THE APPLICATION FOR MINOR WORK PERMIT AND THE PHYSICIAN’S CERTIFICATE BEFORE TURNING IN TO:
Groveport Madison High School

4475 S. Hamilton Rd., Groveport, OH 43125

(614) 836-4971 Monday-Friday 7:30 a.m. – 2:30 p.m.

2. ALL 3 SECTIONS OF THE APPLICATION MUST BE COMPLETED BEFORE THE PERMIT CAN BE ISSUED

a.

b.

c.

Page 1 - Application for Minor Work Permit - Student information (including parent name, address, signature, and phone number)
Page 1 - Employer information (including employer’s name, address, phone number, Tax ID number, signature, and approximate days and hours of work schedule)
Page 2 - Physician’s Certificate for Minor Work Permit – A current physical is required.
	Students
	
must have their doctor sign the “physician’s approval” section AND stamp the form with the
		
doctor’s office stamp.
	If the student changes jobs, he/she will need to complete another

application (1st page only if their physical is current). If the physical we have on file is current, we can make a copy of your doctor information from their previous application. Physicals expire one (1) year after the date of student’s initial doctor visit. If the physical has expired, the student must
complete another physical and have the new form signed and stamped by the doctor.

The mission of Groveport Madison Schools is to build a community of learners, leaders and responsible citizens. _______________________________________________

Every Student, Every Lesson, Every Day

APPLICATION FOR MINOR WORK PERMIT

3331.02 ORC 4109.02 ORC

	STUDENT / APPLICANT INFORMATION

Name of Student / Applicant in full:	Sex:

Male

Grade Level:

Female

Proof of Age (Type of document):

Address of Student /Applicant:

Age:	Date of Birth:	Physician’s certificate:

Submitted with this application

Valid physician’s certificate on file

School District:

Parent or Guardian:

Building:

Parent or Guardian Telephone Number:

Address of Parent or Guardian:

I HEREBY CERTIFY THAT TO THE BEST OF MY KNOWLEDGE AND BELIEF THE ABOVE STATEMENTS ARE TRUE AND THAT THE MINOR NAMED ABOVE WILL WORK WITH MY APPROVAL.
X

Signature of Parent or Guardian

Date Signed

THE NUMBER OF HOURS OR DAYS AND THE TIMES DISPLAYED BELOW OR ON THE FINAL PERMIT ARE FOR REGULATORY PURPOSES ONLY AND ARE NOT TO BE CONSTRUED IN ANY WAY OR MANNER TO BE INDICATIVE OF A CONTRACT BETWEEN AN EMPLOYER AND THE EMPLOYEE.

I HEREBY CERTIFY THAT I HAVE EXAMINED AND APPROVED THE ABOVE NOTED DOCUMENTARY PROOF OF AGE.

X

Superintendent / Chief Adminstrative Officer / Designated Issuing Officer

Name of Office

Address of Office

PLEDGE OF EMPLOYER

Name of Firm:	Telephone Number at Minor’s Work Location:

Address of Student /Applicant’s Place of Employment, Job Site, or Work Location:

Specific Nature of Employment:

Employer’s Tax ID Number (9 digits). THIS FIELD IS MANDATORY

No. of Days Per Week: Hours Per Day:	Starting Time:

1	2	3

Quitting Time:

4

IF MINOR WORKS A VARIED OR IRREGULAR SCHEDULE, ENTER “REPRESENTATIVE” TIMES IN ITEMS 1 THRU 4. ARE HOURS TO BE WORKED WITHIN THE LIMITS OF THE LAW?

YES

NO

THE UNDERSIGNED HEREBY AGREES TO EMPLOY THE ABOVE NAMED CHILD IN ACCORDANCE WITH LAWS REGULATING THE EMPLOYMENT OF MINORS. THE EMPLOYER FURTHER AGREES TO GIVE MINOR A COPY OF THE WAGE AGREEMENT IN ACCORDANCE WITH SEC. 4109.42 ORC. THE EMPLOYMENT WILL BECOME EFFECTIVE AS SOON AS THE NECESSARY AGE AND SCHOOLING CERTIFICATE IS VERIFIED BY THE EMPLOYER. THE EMPLOYER AGREES TO PERMIT THE CHILD TO ATTEND PART TIME SCHOOL WHEN SUCH IS AVAILABLE AND TO NOTIFY THE SCHOOL WITHIN FIVE DAYS AFTER THE EMPLOYMENT OF THE CHILD TERMINATES

X

Signature of person authorized to sign for employer	Date signed	Telephone number

Address of employer if different from minor’s place of employment

LAWS COM 0000 (Replaces Ohio Form II & III)

E-Mail address
(Optional- if employer wants notification in case of revocation)

PHYSICIAN’S CERTIFICATE FOR MINOR WORK PERMIT

3331.02 ORC 4109.02 ORC

	APPLICANT INFORMATION

Name of Student / Applicant in full:

Date of Birth:	Height:	Weight:	Color of Hair:

Sex:

Male	Female

Color of Eyes:

ft.	in.	lbs.

Distinguishing Characteristics, if any:

School District:

Parent or Guardian:

Building:

Parent or Guardian Telephone Number:

PHYSICIAN’S APPROVAL

THE UNDERSIGNED HEREBY CERTIFIES THAT THEY HAVE THOROUGHLY EXAMINED THE ABOVE NAMED APPLICANT WHO WAS BORN ON THE DATE STATED ABOVE, AND WHO MEETS THE DESCRIPTION GIVEN HEREON, AND THAT SAID PERSON;

NOTE: IF WORK SHOULD BE LIMITED TO A CERTAIN TYPE OF EMPLOYMENT, THE PHYSICIAN MUST MARK THIS FORM ACCORDINGLY IN THE AREA BELOW.

IS	IS NOT	Limited Certificate:	YES	NO

IN THEIR OPINION PHYSICALLY FIT TO PERFORM THE WORK OF ANY EMPLOYMENT NOT FORBIDDEN BY LAW TO A PERSON OF THIS AGE AND SEX.

If Marked YES;
Employment should be Limited to Work Specified Below:

X
Physician’s Signature

Date Signed

LAWS COM 0000 (Replaces OHIO FORM V)