Please read the instructions prior to downloading the form. To print the instructions listed below, you may click the link labeled "Print It" on the left hand navigation. View and print the PDF version of the Child Abuse History Clearance Form now. To request a supply of the forms, please call (717)783-6211.

1. Type or print clearly and neatly in ink Section I only.



2. Address must be Applicant's current home address.



3. All information must be completed in full. (The form asks for all previous names, addresses, and household members since 1975). This information must be provided to the best of your knowledge and belief. If necessary, attach additional pages.



4. Application must be signed.



5. Enclose a $10.00 money order for each application. No cash or personal checks accepted. Agency or business checks are acceptable.



6. Do not send any postage paid return envelopes.



7. Application should be placed in a business-sized or larger envelope prior to mailing.



8. One block must be checked for Purpose for Clearance. Do not check more than one block.
   
   
   1. Check the Volunteer Block if performing a service (paid or unpaid) for organizations such as Big Brothers/Big Sisters, Boy Scouts, Little League or churches. A copy of your Criminal Record Check results obtained within the past year must be attached. Do not send original Criminal Record results. If you are not a Pennsylvania resident, you must also attach a copy of your FBI results obtained within the past year. This block should not be checked for anyone volunteering in schools.
   
   
   
   2. Check the School Block if seeking to have involvement within a school (public, private vocational, technical, nursing) for any reason.
   
   
   
   3. Check the Foster Care Block if applying for foster parenting or custody of a child.
   
   
   
   4. Check the Adoption Block if in the process or planning to adopt a child.
   
   
   
   5. Check the Child Care Block if planning to work in a day care setting or if all other blocks do not apply.
   
   
   
   6. Check the CWEP Block if you are participating in a Department of Public Welfare training program. The signature and phone number of the County Assistance Representative is required.

Clearance results will be mailed to you within 14 days from the date that the clearance is received in our office. There will be no replacements after 90 days.

Failure to comply with the above instructions will cause considerable delay.

Please contact the following for applicable criminal history requests:

Pennsylvania Child Abuse History Clearance Form