Disclosure Statement

In addition to the crimes already outlined above, if I am an individual being employed in a child care center, group child care home, or family child care home, I swear/affirm that I have not been convicted of any of the following crimes under Title 18 of the Pennsylvania consolidated statutes or equivalent crime 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 swear/affirm that 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 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 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.