Application for Working Papers Instructions
a Part I must be signed by a Parent or Guardian
b. Be sure to have a Parent or Guardian sign Part I
a. If you are not attending school bring in Evidence of Age.
a. The Physical Fitness Certification MUST be signed.
1. If you have a recent physical on file with the school nurse she will sign the form OR your doctor can sign the form.
2. Your last physical must be within one year of the date of this application.
b. This certificate is not required for Newspaper Carrier permits if the applicant is qualified to participate in the school’s physical education program.
a. Only students who are 16, not attending school full time, and are applying for full time employment, Pledge of Employment must be completed.
Return Forms to: Mrs. Horner – High School Main Office (845) 457-2400 ext. 17525
THE UNIVERSITY OF THE STATE OF NEW YORK
THE STATE EDUCATION DEPARTMENT
Albany, New York 12234
PHYSICAL FITNESS CERTIFICATION
_________________________________ ____________________________________________ (Name of Applicant)
(Date of Birth)
INSTRUCTIONS TO PHYSICIAN: Complete Part A unless certificate is limited --in which case complete Part B
A. I hereby certify that I have examined the above-named applicant and find he/she is physically qualified for lawful employment. _______________________________ ____________________________________________ (Date of Physical) /(Signature of Physician) _____________________________________________________________________________________ (Address of Physician)
B. I hereby certify that I have examined the above-named applicant and find he/she has a disability that requires limited employment.
(1) Disability ---
(2) Occupation ---
(3) Employer --- _______________________________ ____________________________________________ (Date)/ (Signature of Physician)
_____________________________________________________________________________________ (Address of Physician)
If a limited certificate is indicated, the disability, occupation, and employer must be indicated to make this certificate valid.