Houston – Updated Minor Certification Number

Child’s Legal First Name: *

Child’s Legal Last Name: *

Child’s Certification Number from GA Dept. of Labor: *

Please be sure to input the full number including the first letter of the Certification Number.

Child’s Date of Birth: *

Last Four Digits of Child’s Social Security Number: *

(required by GA Dept. of Labor)

Child’s Gender: * Male Female Non-Binary Transgender Intersex Other

Parent/Guardian’s First and Last Name: *

Parent/Guardian's First and Last Name:

First

First

Last

Last

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