CLCC Confidentiality Agreement /Conflict Of Interest Form

Confidentiality Agreement 2025-2026

Child Life Certification Commission Participation Agreement
I, name, accept the position of position on the (Committee/Task Force/Work Group Name) Child Life Certification Commission (CLCC). My service will begin on Date and will be completed on Date .
I understand and agree to the following:

1.   During my entire period of service. I will hold and maintain the CCLS credential with good standing.

2.   I agree to fulfill the entire terms and conditions of this commitment to the best of my ability.

3.  I will read the terms, procedures and policies outlined in the Policies Manual and orientation document.

4.   I will commit to and participate in meetings of my committee(s) to the best of my ability.

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If I am not able to complete my term, I agree to the following;

1. To provide the CLCC Staff Liaison and the CLCC Chairperson a minimum of 2 weeks’ notice.

2.  To make a plan of transition in collaboration with the leadership of the Commission.

3. To assist any incoming volunteer in their transition by sending documents, communicating goals and objectives, key responsibilities and activities.

Initial

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Confidentiality Agreement

1.   I acknowledge that I have been fully informed about the need for complete security and confidentiality in the handling of all information and materials relating to the Child Life Professional Certification Program and the individuals involved in the process, including those applying to sit for the Child Life Professional Certification Examination and all CCLS credential holders.

2.   I will not disclose an individual’s confidential information to anyone, except 1) as mandated by law; 2) to prevent a clear and immediate danger to a person or persons; 3) where I am compelled to do so by a court or pursuant to the rules of a court.

3.   I agree that I will not allow any breach in security regarding the certification examination, the CLCC Item Bank, or any other exam-related information and will report any breach that I witness or come to know about. I affirm that I know of no past breach of confidentiality.

4.   I understand that if I violate any of these requirements, or any CLCC policy or procedure, I may be subject to a review by the CLCC Ethics Committee and potential legal action.

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Initial
Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date
Conflict-of-Interest Disclosure Form 2025-2026

Child Life Certification Commission (CLCC)
As a volunteer for the CLCC, I recognize that CLCC must provide bias-free governance, and that I owe a duty of loyalty to CLCC. I further recognize that one aspect of fulfilling my duty is to disclose “other interests.” I am therefore disclosing the following. I will provide further information if requested and will cooperate with any review and evaluation on behalf of CLCC. (Note: you must disclose these “other interests” both personally, and for family members or close business associates.) Please indicate whether any information provided here is to be kept confidential by CLCC.
a. Any ownership interest, employment, or volunteer position or involvement in a commercial entity or nonprofit organization that may be seen as competing with CLCC or its programs and services, or vying for the same members or customers as CLCC:*
Write N/A if not applicable
b. Any ownership interest, employment, or volunteer or other involvement, in a commercial entity or nonprofit organization that is, or seeks to be, a vendor of products or services to CLCC:*
Write N/A if not applicable
c. Any position as spokesperson, consultant, employee, or agent for another commercial or nonprofit organization that advances opposing or adverse public policy positions from those of CLCC*
Write N/A if not applicable
OR
Initial I do not have "other interests" to disclose at this time.
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Some CLCC positions may not be filled by academicians. Are you involved in preparing students for the Child Life Professional Certification Examination?

YES or NO Initial one
If so, In what capacity?
Transfer of Copyrights

InitialI hereby irrevocably transfer and assign to the Child Life Certification Commission, located at 8843 Greenbelt Road, #261, Greenbelt, MD, its successors and assigns, in perpetuity, all right (whether now known or hereinafter invented), title, and interest, throughout the world, including any copyrights and renewals or extensions thereto, in the Child Life Professional Certification Examination Item Bank, including any test items I may write and/or review.
Name*

First NameLast Name
Committee/Task Force/Work Group:blanks
Term of Office Date to Date
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Confidentiality Agreement 2025-2026

Conflict-of-Interest Disclosure Form 2025-2026