I have not been convicted of a felony offense under Act 64-172 (relating to the controlled substance, drug device and cosmetic act) committed with the last five years.
I understand that I shall not be approved for service if I am named as a perpetrator of a founded report of child abuse within the last five (5) years or have been convicted of any of the crimes listed above or of offenses similar in nature to those crimes under the laws or former laws of the United States or one of its territories or possessions, another state, the District of Columbia, the Commonwealth of Puerto Rico or a foreign nation, or under a former law of this Commonwealth.
I understand that if I am arrested for or convicted of an offense that would constitute grounds for denying participation in a program, activity or service under the Child Protective Services Law as listed above, or are named as perpetrator in a founded or indicated report, I must provide the administrator or designee with written notice no later than 72 hours after the arrest, conviction or notification that I have been listed as a perpetrator in the Statewide database.
I understand that if the person responsible for employment decisions or the administrator of a program, activity or service has a reasonable belief that I was arrested or convicted for an offense that would constitute grounds for denying participation in a program, activity or service under the Child Protective Services Law, or was named as perpetrator in a founded or indicated report, or I have provided notice as required under this section, the person responsible for employment decisions or administrator of a program, activity or service shall immediately require me to submit current clearances obtained through the Department of Human Services, the Pennsylvania State Police, and the Federal Bureau of Investigation, as appropriate. The cost of clearances shall be borne by the employing entity or program, activity or service.
I understand that if I willfully fail to disclose information required above, I commit a misdemeanor of the third degree and shall be subject to discipline up to and including denial of a volunteer position.
I understand that the person responsible for employment decisions or the administrator of a program, activity or service is required to maintain a copy of my clearances.
I hereby swear/affirm that the information set forth above is true and correct. I understand that false swearng is a misdemeanor pursuant to Section 4903 of the Crimes Code.