Volunteer Affidavit Form printable pdf download

Manheim Central School District

Preparing Responsible Citizens, Who Are Lifelong Learners

261 White Oak Road

Manheim, PA 17545

Telephone: 717.664.8540; Fax: 717.664.8539

Norman E. Hatten, D.Ed. – Superintendent

Peter J. Aiken, Ed.D. – Assistant Superintendent

VOLUNTEER AFFIDAVIT

SECTION 1: Personal Information-

Name:

____________________________________________

Date: _______________________________

Address:

___________________________________________________________________________________

Telephone: ___________________________________________

SECTION 2: Volunteer Information-

Volunteer Position(s): Please check the appropriate box below.

☐ VOLUNTEER/ FIELD TRIP CHAPERONE

☐ VOLUNTEER COACH / OVERNIGHT FIELD TRIP CHAPERONE

I, ___________________________, (Name) hereby attest that all information provided below is correct and current. I understand that if

this any false statements can and will be punishable by law.

I hereby attest and understand that the volunteer position for which I am applying is an unpaid position.

I hereby swear and affirm that I have not been convicted of any of the following offenses under Title 18 (relating to crimes and

offenses), or any offense similar in nature to the crimes listed below, 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 2709.1 (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 of children).



Section 4305 (relating to dealing in infant children).



A felony offense under section 5902(b) (relating to prostitution and related offenses).



Section 5903(c) or (d) (relating to obscene and other sexual materials and performances).



Section 6301 (relating to corruption of minors).



Section 6312 (relating to sexual abuse of children).



The attempt, solicitation or conspiracy to commit any of the offenses set forth in this list.



A felony offense under the act of April 14, 1972 (P.L. 233, No. 64) known as The Controlled Substance, Drug, Device

and Cosmetic Act, committed within the five-year period immediately preceding verification under this section.

9/14/2015

Volunteer Affidavit Form

Related Articles

Related forms

Related Categories