Application For Provisional Employment In A Child-Care Service

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DISCLOSURE STATEMENT
APPLICATION FOR PROVISIONAL EMPLOYMENT IN A CHILD-CARE SERVICE
Required by the Child Protective Service Law
23 Pa. C.S. Section 6344 (relating to information relating
to prospective child-care personnel)
I swear/affirm that I have mailed the requests for clearance to ChildLine and the Federal Bureau of
Investigation.
I swear/affirm that I have not been named as a perpetrator of a founded report of child abuse or as an
individual responsible for a founded report for a school employee as defined by the Child Protective
Services Law.
I swear/affirm that I have not been convicted of any of the following crimes under Title 18 of the
Pennsylvania consolidated statues or equivalent crime in another state.
Chapter 25
(relating to criminal homicide)
Section 2702
(relating to aggravated assault)
Section 2709
(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)
Section 5902(b)
(relating to prostitution and related offenses)
Section 5903(c) (d)
(relating to obscene and other sexual material and performances)
Section 6301
(relating to corruption of minors)
Section 6312
(relating to sexual abuse of children), or an equivalent crime under
Federal law or the law of another state.
I have not been convicted of a felony offense under Act 64-1972 (relating to the controlled substance,
drug device and cosmetic act) committed within the past five years.
I understand that my employment must be terminated if I am named as a perpetrator of a founded report
of child abuse within the past five (5) years or have been convicted of any of the crimes listed above.

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