Background Check Signature Form                                             
 
Under the new Pennsylvania state law all Volunteers must obtain and submit the following   clearances :  Criminal History Clearance from the PA State Police – https://epatch.state.pa.us/  Child Abuse History Clearance from the Dept. of Human Services – https://www.compass.state.pa.us/cwis/public/home 
 
Additionally -the volunteer must have resided within the state of PA for the past 10yrs & swear or affirm in writing that they are not disqualified from service based upon a conviction of an offense listed below under code 6344 (c) ***If the volunteer has NOT resided in the state of Pennsylvania for the last 10yrs FINGERPRINTING PROCESS IS REQUIRED*** 
 
By signing the bottom of this document you are stating the you have : 1. Lived in the State of PA for the last 10years 2. Have not been convicted of any of the offenses listed  in section (c) to disqualify your participation 
 
              (c)  Grounds for denying employment or participation in program, activity or service.-- (1)  In no case shall an administrator hire or approve an applicant where the department has verified that the applicant is named in the state wide database as the perpetrator of a founded report committed within the five-year period immediately preceding verification pursuant to this section. (2)  In no case shall an administrator hire an applicant if the applicant's criminal history record information indicates the applicant has been convicted of one or more of the following offenses under Title 18 (relating to crimes and offenses) or an equivalent crime under Federal law or the law of another state: Chapter 25 (relating to criminal homicide). Section 2702 (relating to aggravated assault). Section 2709.1 (relating to stalking). Section 2901 (relating to kidnapping). Section 2902 (relating to unlawful restraint). Section 3121 (relating to rape). Section 3122.1 (relating to statutory sexual assault). Section 3123 (relating to involuntary deviate sexual intercourse). Section 3124.1 (relating to sexual assault). Section 3125 (relating to aggravated indecent assault). Section 3126 (relating to indecent assault). Section 3127 (relating to indecent exposure). Section 4302 (relating to incest). Section 4303 (relating to concealing death of child). Section 4304 (relating to endangering welfare of children). Section 4305 (relating to dealing in infant children). A felony offense under section 5902(b) (relating to prostitution and related offenses). Section 5903(c) or (d) (relating to obscene and other sexual materials and performances). Section 6301 (relating to corruption of minors). Section 6312 (relating to sexual abuse of children). The attempt, solicitation or conspiracy to commit any of the offenses set forth in    this paragraph. (3)  In no case shall an employer, administrator, supervisor or other person responsible for employment decisions hire or approve an applicant if the applicant's criminal history record information indicates the applicant has been convicted of a felony offense under the act of April 14, 1972 (P.L.233, No.64), known as The Controlled Substance, Drug, Device and Cosmetic Act, committed within the five-year period immediately preceding verification under this section. (c.1)  Dismissal.--If the information obtained pursuant to subsection (b) reveals that the applicant is disqualified from employment or approval pursuant to subsection (c), the applicant shall be immediately dismissed from employment or approval. 
 
First/Last Name _________________________________________________                                            (please print) 
 
Signature _______________________________________________________                  Date__________________