Application For Provisional Employment In A Child-Care Service (Page 2 of 2) in pdf

Application For Provisional Employment In A Child-Care Service Page 2

I understand that my employment may be terminated if I have been named as the perpetrator of an

indicated or founded report of child abuse or as an individual responsible for the injury or abuse in a

founded or indicated report for a school employee.

I hereby swear/affirm that the information as set forth above is true and correct. I understand that the

penalty for false swearing is a misdemeanor of the third degree pursuant to Section 4903(b) of the

Criminal Code.

Name:

_______________________________Signature:__________________________________

Witness: _______________________________Signature:___________________________________

Date:

________________________

Application For Provisional Employment In A Child-Care Service Page 2