YMCA of Greater Erie

The YMCA of Greater Erie’s priority is the safety of our members and program participants. In order to ensure the safety of YMCA participants, the YMCA of Greater Erie will perform background checks on volunteers, who will work with children, or may come in contact with children during the course of their volunteer experience. Such individuals will be required to maintain satisfactory records as a condition of volunteerism. In addition, the YMCA of Greater Erie may periodically perform background checks randomly on volunteers who have been previously checked and who continue to be involved in a position with the YMCA of Greater Erie whereby YMCA policy would require such background checks of such individual.

I swear/affirm that I am seeking a volunteer position and AM NOT required to obtain a certification through the Federal Bureau of Investigation (FBI), as:

the position I am applying for is unpaid; and
I have been a resident of Pennsylvania during the entirety of the previous ten-year period.

I understand that if I have not been a resident of Pennsylvania during the entirety of the previous ten-year period, but have received certification from the FBI since establishing residency. I must provide a copy of the certification to my employer and am not required to obtain any additional FBI certifications.

I swear/affirm that, if providing certifications that have been obtained within the preceding 60 months, I have not been disqualified from service as outlined below or have not been convicted of an offense similar in nature to a crime 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.

In consideration of my volunteer eligibility (or continued volunteer eligibility if I am currently a volunteer) with the YMCA of Greater Erie:

Full Name*

I, ___________(Name)_______________, hereby authorize and give consent for the YMCA of Greater Erie to run a background check to ensure my qualifications as a volunteer.

I swear/affirm that I have not been named as a perpetrator of a founded report of child abuse within the past five (5) years as defined by the Child Protective Services Law. I swear/affirm that I have not been convicted of any of the following crimes under Title 18 of the Pennsylvania consolidated statues or of offenses similar in nature to those crimes 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:

I swear/affirm that I have not been convicted of a felony offense under Act 64-1972 (relating to the controlled substance, drug devise and cosmetic act) committed within the past five years. I understand that I shall not be approved for service if I am named a perpetrator of a founded report of child abuse within the past five (5) years or have been convicted of any of the crimes listed above or of offenses similar in nature to those crimes 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. I understand that if I am arrested for or convicted of an offense that would constitute grounds for denying participation in a program, activity or service under the Child Protective Services Law as listed above, or am named as perpetrator in a founded or indicated report, I must provide the administrator or designee with written notice not later than 72 hours after the arrest, conviction or notification that I have been listed as a perpetrator in the Statewide database. I understand that if the administrator of a program, activity or service has a reasonable belief that I was arrested or convicted for an offense that would constitute grounds fro denying participation in a program, activity or service under the Child Protective Services Law, or was named as perpetrator in a founded or indicated report, or I have provided notice as required under this section, the administrator of a program, activity or service shall immediately require me to submit current certifications obtained through the Department of Human Services, the Pennsylvania State Police, and the Federal Bureau of Investigation, as appropriate. The cost of certifications shall be borne by the entity of the program, activity or service. I understand that if I willfully fail to disclose information required above, I commit misdemeanor of the third degree and shall be subject to discipline up to and including denial of a volunteer position. I understand that certifications obtained for the volunteering purposes can only be used for that purpose and cannot be used for employment purposes. I understand that the person responsible for the administrator of a program, activity or service is required to maintain a copy of my certifications. I understand that I must be dismissed if I am named as a reported sex offender or listed on the National Sex Offender registry or have been convicted of any of the crimes listed above. I understand that I am not under obligation to pay for the background check and that YMCA will incur all costs related to the background check. I hereby swear/affirm that the information as set forth above is true and correct. I understand that false swearing is a misdemeanor pursuant to Section 4903 of the Crimes Code. I hereby release from liability and promise to hold harmless under any and all possible claims or causes of action (i) any and all persons or entities who shall furnish such information to the YMCA of Greater Erie, its officers, agents or employees, and (ii) the YMCA of Greater Erie, its officers, agents or employees for any statements, acts or omissions in the course of obtaining said information. Furthermore, I understand that this release is signed, free from duress, and with the full knowledge and understanding that any information obtained will be used in assessing my relative volunteer eligibility with the YMCA of Greater Erie. *

I swear/affirm that I have not been convicted of a felony offense under Act 64-1972 (relating to the controlled substance, drug devise and cosmetic act) committed within the past five years.

I understand that I shall not be approved for service if I am named a perpetrator of a founded report of child abuse within the past five (5) years or have been convicted of any of the crimes listed above or of offenses similar in nature to those crimes 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.

I understand that if I am arrested for or convicted of an offense that would constitute grounds for denying participation in a program, activity or service under the Child Protective Services Law as listed above, or am named as perpetrator in a founded or indicated report, I must provide the administrator or designee with written notice not later than 72 hours after the arrest, conviction or notification that I have been listed as a perpetrator in the Statewide database.

I understand that if the administrator of a program, activity or service has a reasonable belief that I was arrested or convicted for an offense that would constitute grounds fro denying participation in a program, activity or service under the Child Protective Services Law, or was named as perpetrator in a founded or indicated report, or I have provided notice as required under this section, the administrator of a program, activity or service shall immediately require me to submit current certifications obtained through the Department of Human Services, the Pennsylvania State Police, and the Federal Bureau of Investigation, as appropriate. The cost of certifications shall be borne by the entity of the program, activity or service.

I understand that if I willfully fail to disclose information required above, I commit misdemeanor of the third degree and shall be subject to discipline up to and including denial of a volunteer position.

I understand that certifications obtained for the volunteering purposes can only be used for that purpose and cannot be used for employment purposes.

I understand that the person responsible for the administrator of a program, activity or service is required to maintain a copy of my certifications.

I understand that I must be dismissed if I am named as a reported sex offender or listed on the National Sex Offender registry or have been convicted of any of the crimes listed above.

I understand that I am not under obligation to pay for the background check and that YMCA will incur all costs related to the background check.

I hereby swear/affirm that the information as set forth above is true and correct. I understand that false swearing is a misdemeanor pursuant to Section 4903 of the Crimes Code.

I hereby release from liability and promise to hold harmless under any and all possible claims or causes of action (i) any and all persons or entities who shall furnish such information to the YMCA of Greater Erie, its officers, agents or employees, and (ii) the YMCA of Greater Erie, its officers, agents or employees for any statements, acts or omissions in the course of obtaining said information. Furthermore, I understand that this release is signed, free from duress, and with the full knowledge and understanding that any information obtained will be used in assessing my relative volunteer eligibility with the YMCA of Greater Erie.

Authorization*

I hereby acknowledge the information outlined above and I also authorize the YMCA of Greater Erie to obtain such records.

Hidden

Authorization (old)

By my name below, I hereby acknowledge the information outlined above and I also authorize the YMCA of Greater Erie to obtain such records.

Name*

First Last

Signature*

Date*

Background Check Waiver