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GSEP Disclosure Affidavit PA Act 153 Compliance

I, the undersigned, swear and affirm the following statements of fact: 

I am applying for the opportunity to serve as an unpaid volunteer for the Girl Scouts of Eastern Pennsylvania

 Yes

Choose Statement A or B

Statement A
I have been a resident of the Commonwealth of Pennsylvania during the entirety of the ten-year period preceeding the date of this Affidavit. 

  1. I am not disqualified from service as an unpaid volunteer with GSEP pursuant to 23 Pa C.S.A.  Section 6344(c), a copy of which is attached hereto, and have not been convicted of offenses of a similar nature to those crimes listed therein under the laws or former laws of the United States or one of it's 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. 
  2. The commencement of my volunteer service is contigent upon me obtaining and submitting  to GSEP my 1) criminal history record information from the Pennsylvania State Police and 2) a certification from the Pennsylvania Department of Human Services regarding my status as a perpetrator of child abuse, pursuant to 23 Pa.C.S.A. Section 6344(b), and my subsequent approval for service from the organization.  
 Statement A Applies to Me
 Statement A Does Not Apply to Me

Statement B
I have NOT been a resident of the Commonwealth of Pennsylvania during the entirety of the ten-year period preceeding the date of this Affidavit. 

  1. The commencement of my volunteer service is contingent upon me obtaining and submitting to GSEP my 1) criminal history record information from the Pennsylvania State Police, 2) a certification from the Pennsylvania Department of Human Services regarding my status as a perpetrator of child abuse and 3) a Federal Bureau of Investigation (FBI) Criminal Background Check pursuant to 23 Pa.C.S.A Section 6344(b), and my subsequent approval for service from the organization.  
 Statement B Applies to Me
 Statement B Does Not Apply to Me

I understand that I am required to obtain and submit the reports referenced in the above paragraph every 60 months, and that failure to do so will result in revocation of my approval as an unpaid volunteer. 

 Yes

I understand that if I have been named as a perpetrator of a founded report of child abuse within the past five (5) years as defined by the Child Protective Services Law, I am disqualified as a GSEP volunteer

I understand that if I have ever been convicted of any of the following crimes under Title 18 of the Pennsylvania consolidated statues or of offenses similar in nature to those crimes 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 am disqualified as a GSEP volunteer.

Chapter 25 (relating to criminal homicide) Section 3127 (relating to indecent exposure)
Section 2702 (relating to aggravated assault) Section 4302 (relating to incest)
Section 2709 (relating to stalking) Section 4303 (relating to concealing death of a child)
Section 2901 (relating to kidnapping) Section 4304 (relating to endangering welfare of children)
Section 2902 (relating to unlawful restraint)  Section 4305 (relating to dealing in infant children)
Section 3121 (relating to rape) Section 5902(b) (relating to prostitution and related offenses)
Section 3122.1 (relating to statutory sexual assault) Section 5903(c)(d) (relating to obscene and other sexual material and performances) 
Section 3123 (relating to involuntary deviant sexual intercourse) Section 6301 (relating to corruption of minors)
Section 3124.1 (relating to sexual assault) Section 6312 (relating to sexual abuse of children)
Section 3125 (relating to aggravated indecent assault) Or, an equivalent crime under Federal law or the law of another state
Section 3126 (relating to indecent assault)  
 Yes

I understand that if I have been convicted of a felony offense under Act 64-1972 (relating to controlled substance, drug device, and cosmetic act) committed within the past 5 years, I am disqualified as a GSEP volunteer.

 Yes

I understand that I shall not be approved for service if I am named as a perpetrator of a founded report of child abuse in the last five (5) years or have been convicted of any of the crimes above or of offenses similar in nature to those crimes under the laws or former laws of the United States, one of its territories or possessions, another state, the District of Columbia, the Commonwealth of Puerto Rico or a foreign nation, or under the former law of this Commonwealth. 

 Yes

I understand that if I am arrested or convicted for ANY offense - especially one that would constitute grounds for denying participation in a program, activity, or service under the Child Protective Services Law as listed above, or am named as a perpetrator in a founded or indicated report, I must provide the administration 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. 

 Yes

I understand that if the person responsible for employment decisions of the administration 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 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 clearanced obtained through the Department of Human Services, the Pennsylvania State Police, and the Federal Bureau of Investigation, as appropriate. The cost of clearances shall be borne by the employing entity or program, activity, or service. 

 Yes

I understand that if I willfully fail to disclose information required above, I committ a misdemeanor of the third degree and shall be subject to discipline up to and including denial of a volunteer position. 

 Yes

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 clearances. 

 Yes

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. 

 Yes

I swear and affirm that the foregoing facts are true and correct. I also swear and affirm that if the facts I swear on this form become incorrect, I will immediately notify GSEP. I understand that providing false information will result in revocation of approval of my volunteer status. 

Pursuant to 28 U.S.C. Section 1746, I declare under penalty of perjury that the foregoing is true and correct. 

By entering your name and checking the "I Accept" button below, you are signing this application electronically, and are confirming that you have read and agree with the above statements. You agree that your electronic signature is the equivalent of your manual/handwritten signature. 

 I Accept
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