AFFIDAVIT OF VOLUNTEER FOR CHILDREN’S PROGRAMS

  1. My full name and address are as follows: _________________________________ ________________________________________________________________________ ____________________________________________________________
  2. I am an unpaid volunteer.
  3. I have been a resident of the Commonwealth of Pennsylvania during the entirety of the previous ten (10) year period.
  4. By signing below, I swear or affirm that I am neither a perpetrator of a founded report of child abuse nor named in any Registry as the perpetrator of a founded report of child abuse.
  5. I further swear or affirm that I have never been convicted of or pled guilty to any of the following offenses: criminal homicide; aggravated assault; stalking; kidnapping; unlawful restraint; rape; statutory sexual assault; involuntary deviate sexual intercourse; sexual assault; aggravated indecent assault; indecent assault; indecent exposure; incest; concealing the death of a child; endangering the welfare of children; dealing in infant children; prostitution and related offenses; obscene and other sexual material and performances; corruption of minors; sexual abuse of children; or the attempt, solicitation or conspiracy to commit any of the aforementioned offenses.
  6. I further attest and certify that I have not been convicted of an offense designated as a felony under the Controlled Substance, Drug, Device and Cosmetic Act.
  7. I further attest and certify that I have not been convicted of an out-of-state or Federal offense similar in nature to the foregoing offenses listed in Paragraphs 5 and 6 above.I hereby swear or affirm that the statements set forth above are true and correct.

    __________ _____________________________ Dated Signature

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