Consent/release Of Information Authorization Form For The Pennsylvania Child Abuse History Clearance - Milestone Academy

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700 N. Cedar Road
Jenkintown, PA 19046
CONSENT/RELEASE OF INFORMATION AUTHORIZATION FORM FOR THE PENNSYLVANIA CHILD
ABUSE HISTORY CLEARANCE
I, ________
___________________________ hereby authorize the Department of
(Insert name )
Public Welfare, Childline to release my Pennsylvania Child Abuse History Clearance
information directly to
MileStone Academy
in Jenkintown PA.
I understand that this information is confidential in nature pursuant to §6340 (relating to
information in confidential reports) of the
Child
Protective Services Law (CPSL) (23 Pa.C.S
Chapter 63) and will not otherwise be released by
MileStone Academy
without my express
authorization or pursuant to authorization
by
Title 55 of the Pennsylvania
Code.
I understand
that the aforementioned information will not be released directly to me ______
(insert name
___________________ as stated in the Pennsylvania Child Abuse History Clearance
application. I understand that I will not receive a copy of my Pennsylvania Child Abuse History
Clearance directly from
Childline; however,
I may request a copy of my Pennsylvania Child
Abuse History Clearance from
MileStone Academy
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 Clearance application as it otherwise relates to this consent.
_________________________________________
______________________
Applicant Signature
Date
M
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S
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otivated
ntelligent
earners
mploying
trategies
o
vercome and
avigat
through
ducation

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