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Pennsylvania Child Protection Background Clearance Submission - Pennsylvania Dutch Council, Boy Scouts Of America

Pennsylvania Dutch Council

Boy Scouts of America

Pennsylvania Child Protection Background Clearance Submission

PA ACT 153

To be completed by the Unit Youth Protection Chair or Other Unit Designee:

Council: ______________________________

District: ____________________________________

Unit Number: _____ Chartered Organization: _____________________________________________

Unit Type (Check One): _____ Pack _____ Troop _____ Team _____ Crew _____ Ship _____ Post

The individuals listed below have completed the background clearances required under PA

ACT 153 and have submitted reports as originals. Copies of these reports are attached.

Signature: ____________________________________ Date: __________________________________

Print Name: __________________________________ Email: _________________________________

Phone: ______________________________________

Required Clearance Reports:

1. Pennsylvania State Police Criminal History Check Report – Enter Date Below

2. PA Dept. of Human Services Child Abuse Clearance Report – Enter Date Below

3. Fingerprint-Based FBI Criminal History Check Report OR Exemption Disclosure Statement Form

a. Enter Date below if Fingerprinted or EXEMPT if exempt

Name

PA State Police

Child Abuse

FBI or Exemption

(Enter Date)

(Enter Date or EXEMPT)

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Pennsylvania Child Protection Background Clearance Submission - Pennsylvania Dutch Council, Boy Scouts Of America