Lancaster Rec Volunteer Application

Lancaster Rec Volunteer Application
Name*
Today's Date*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Cell Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Date of Birth*

MonthDayYear
Date
Social Security Number*
Occupation
Employer
Employer Address
Special professional training, skills, hobbies, etc.
Community Affiliations (clubs, service organizations)
Previous Volunteer Experience
YesNo
Special Certifications Held (CPR, medical, etc.)
YesNo
YesNo
If the answer is "Yes" to either of these questions, please give the nature of the crime, dates of convictions, and the court in which you were convicted.*
YesNo
If "Yes", please explain:*
YesNo
YesNo
Upload a picture of your photo ID here.*

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CoachReferee/UmpireField MaintenanceConcession StandProgram FacilitatorFacility MaintenanceBefore/After School ProgramSummer Day CampDance

Please list three references, at least one of which has knowledge of your participation as a volunteer in a youth program. (Names and phone numbers)

Rows	Name	Phone Number
Reference 1
Reference 2
Reference 3

As a condition of volunteering, I give permission for the Lancaster Recreation Commission to conduct a background check on me, which may include a review of sex offender registries, child abuse and criminal history records. I understand that, if appointed, my position is conditional upon the Lancaster Recreation Commission receiving no inappropriate information on my background. I hereby release and agree to hold harmless from liability the Lancaster Recreation Commission, its officers, employees and volunteers thereof, or any other person or organization that may provide such information. I also understand that, regardless of previous appointments, the Lancaster Recreation Commission is not obligated to appoint me to a volunteer position. If appointed, I understand that, prior to the expiration of my term, I can be subject to suspension and removal from my volunteer position for violation of Lancaster Recreation Commission policies or principles.
Signature*

Clear
NOTE: Lancaster Recreation Commission does not discriminate against any person on the basis of race, creed, national origin, marital status, gender, sexual orientation or disability.

REQUEST FOR CRIMINAL RECORD CHECK
First Name*
Middle Name
Last Name*
Maiden Name and/or Aliases
Sex*
Race*

PENNSYLVANIA CHILD ABUSE HISTORY CLEARANCE

Information that is needed for this section will be taken from previous answer boxes that you already completed.
AGE*
Daytime Phone Number*
Format: (000) 000-0000.
MaleFemale
COUNTY YOU LIVE IN*
Child Care Services EmployeeFoster CareAdoptionSchool EmployeeVolunteer
Below, type in any previous names that you have used since 1975. If you have not used any other names (other than your given name), skip this section.
1. (LAST, FIRST, MIDDLE)
2. (LAST, FIRST, MIDDLE)
3. (LAST, FIRST, MIDDLE)
4. (LAST, FIRST, MIDDLE)
5. (LAST, FIRST, MIDDLE)
Please list all addresses that you have lived at since 1975. This information is important for the child abuse form.
1.*
2.
3.
4.
5.
If you have to add an additional sheet, please upload a picture here:

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Household Members since 1975

List anyone that you have lived with since 1975 below. Make sure to include parents, siblings, children, etc. (We need you to fill out each row for each person you write in)*

Rows	Name (Last, First, Middle)	Relationship	Present Age	Sex
1.
2.
3.
4.
5.
6.

If you have to add an additional sheet, please upload a picture here:

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Disclosure Statement Application for Volunteers

Required by the Child Protective Service Law
I swear/affirm that I am seeking a volunteer position and AM NOT required to obtain a clearance through the Federal Bureau of Investigation, as:
- the position I am applying for is unpaid; and
- I have been a resident of Pennsylvania during the entirety of the previous ten-year period.
I swear/affirm that I have not been convicted of any of the following crimes under Title 18 of the Pennsylvania consolidated statutes 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.
- 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 or 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 I shall not be approved for service 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 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 understand that if I am arrested for or convicted of an offense 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 perpetrator in a founded or indictated report, I must provide the administrator or designee with written notice no later than 72 hours after the arrest, conviction or notification that I have been listed as a perpetrator in the Statewide datatbase.

I understand that if the persin responsible for employment decisions or the administrator of a program, activity or service has a responsible 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 clearances 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.

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 denial of a volunteer position.

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.

I hearby 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.
Signature*

Clear

CONSENT/RELEASE OF INFORMATION AUTHORIZATION FORM FOR THE PENNSYLVANIA CHILD ABUSE HISTORY CERTIFICATION
I hereby authorize the PA Department of Human Sevices, ChildLine to release my Pennsylvania Child Abuse History Clearance information directly to the Lancaster Recreation Commission. I understand that this information is confidential in nature pursuant to §6339 (relating to information in confidential reports) of the Child Protective Services Law (CPSL) (23 Pa.C.S Chapter 63) and is not otherwise to be released by the Lancaster Recreation Commission without my expressed authorization or pursuant to Section 3490.126 of Title 55 of the Pennsylvania Code which states this information is confidential and the requesting agency can be held criminally liable for a breach of confidentiality related to release of this information. I also understand that the aforementioned information will not be released directly to me as stated on the Pennsylvania Child Abuse History Certification application. I understand that I will not receive a copy of my Pennsylvania Child Abuse History Certification directly from ChildLine; however, I may request a copy of my Pennsylvania Child Abuse History Certification from the Lancaster Recreation Commission upon written request. I have read this Consent/Release of Information Authorization form and fully understand and agree to its content. I further understand and agree to all information and ramifications of the Pennsylvania Child Abuse History Certification application as it otherwise relates to this consent. Further I understand that if I am listed in the statewide database for child abuse that my consent allows the result stating such information to be shared with the Lancaster Recreation Commission.
Name of Requesting Agency
Date*

MonthDayYear
Date
Applicant's Signature*

Clear

If you already have the Criminal Record Check and Child Abuse Clearance, please submit them below. If not, skip and submit.
Criminal Record Check

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Child Abuse Clearance

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Should be Empty:

Lancaster Rec Volunteer Application

REQUEST FOR CRIMINAL RECORD CHECK

PENNSYLVANIA CHILD ABUSE HISTORY CLEARANCE

Below, type in any previous names that you have used since 1975. If you have not used any other names (other than your given name), skip this section.

Please list all addresses that you have lived at since 1975. This information is important for the child abuse form.

Household Members since 1975

Disclosure Statement Application for Volunteers

CONSENT/RELEASE OF INFORMATION AUTHORIZATION FORM FOR THE PENNSYLVANIA CHILD ABUSE HISTORY CERTIFICATION

If you already have the Criminal Record Check and Child Abuse Clearance, please submit them below. If not, skip and submit.