Clearance Verification Form Logo

  • Clearance Verification Form

  • Biographical Information

    Please complete the information below using your legal biographical information (as indicated on your clearance documents)
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  • Contact Information


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  • Affiliation

  • Clearance Data

    The following questions require information from your clearance forms. Please have these forms nearby when completing the information in following sections.

  • Pennsylvania Child Abuse History Certification

    If you have not completed your Act 151 Pennsylvania Child Abuse History Certification, go to this link: https://www.compass.dhs.pa.gov/cwis/public/home
  • Example Pennsylvania Child Abuse History Certification highlighting the 'Verification Date' field in yellow with a red arrow and label pointing to 4/22/2016. Use this date when filling out the form.
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  • Pennsylvania State Police Response for Criminal Record Check

    If you have not completed your Act 34 Pennsylvania State Police Response for Criminal Record Check, go to this link: https://epatch.pa.gov/home
  • Example Pennsylvania State Police Criminal Record Check response highlighting the 'Date of Request' field in yellow with a red arrow and label pointing to 04/22/2016 01:43 PM. Use this date when filling out the form.
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  • Act 114 Criminal History Report

    If you have not completed your Act 114 Criminal History Report go to this link: https://uenroll.identogo.com/workflows/1KG6ZJ The requirement to obtain the Act 114 Criminal History Report can be waived if the volunteer is unpaid, can prove that s/he has lived in Pennsylvania for at least 10 years, and signs a Disclosure Statement affirming that s/he did not commit certain crimes elsewhere. Volunteers who have not resided in Pennsylvania for the past 10 years but have obtained their Act 114 Criminal History Report since establishing residency are not required to obtain another Report but must provide a copy of it to the district.
  • Example background check result from the Pennsylvania Department of Human Services highlighting the date '11/29/2022' in yellow with a red arrow and label pointing to it. Use this date for the Date of Fingerprinting field on the form.
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  • Volunteer Disclosure Statement

    This document must be signed, dated and witnessed. It does NOT need to be notarized. As stated on the disclosure statement, you are required to notify the district, in writing within 72 hours if you are arrested for or convicted of an offense that would constitute grounds for denying participation as a volunteer, or you are named as a perpetrator in a child abuse report. Willful failure to do so has criminal implications and may jeopardize your ability to volunteer within the district.
  • Example Pennsylvania Volunteer Disclosure Statement showing signature and date fields for Applicant, Witness, and Parent or Guardian. A red arrow and label indicate to 'Provide the earliest date written in either of these boxes' as the one to use on the form.
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