I understand that I must be dismissed from employment 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.
I understand that if I am being hired on a provisional basis, I am not permitted to work alone with children and
must work in the immediate vicinity of a permanent employee during this provisional employment period.
I understand that if I am arrested for or convicted of an offense that would constitute grounds for denying
employment or participation in a program, activity or service under the Child Protective Services Law as listed
above, or am named as perpetrator in a founded or indicated report, I must provide the administrator or designee
with written notice not 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 employment or 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 certifications obtained through the Department of Human Services, the
Pennsylvania State Police, and the Federal Bureau of Investigation. The cost of certifications 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 termination or denial of employment.
I understand that certifications obtained for employment purposes may be used to apply for employment, serve as
an employee, apply to volunteer and serve as a volunteer.
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 certifications.
I hereby swear/affirm that the information as set forth above is true and correct. I understand that false swearing
is a misdemeanor pursuant to Section 4903 of the Crimes Code.
Name:
_______________________________Signature:__________________________________
Witness: _______________________________Signature:___________________________________
If the employee is a minor:
Parent/Legal Guardian Name: __________________Signature: _________________________________
Date:
_______________________
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