Family Name(s): Relationship: Student Name(s): Grade(s): School Year

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1 250 West King Street, York, PA Phone: (717) School Year Dear Family Volunteers: Family partnerships are a foundational part of the success of Logos Academy. It is through these partnerships that we are able to educate our students with excellence. We rely on each family s investment to ensure that what we teach during the school day is valued and reinforced at home. Logos Academy could not be successful without the help of our family volunteers. Student safety will always be a priority at Logos Academy. In October 2014, Pennsylvania passed a bill requiring all volunteers who have direct contact with any child (anyone under the age of 18 years) to receive clearances and background checks every five years. These new volunteer clearance requirements further support Logos Academy s commitment to providing a safe, secure, learning environment for your children. At Logos Academy, protecting your student is a shared responsibility. We are requiring all Logos families to complete ten (10) hours of volunteer time during this school year, with three options in which to fulfill these required hours. Option A: [Complete pages 1-7; include items from checklist on page 2; return to front desk] I plan to volunteer during regular school hours, and I will have direct contact with children (under 18 years of age). I understand that I will be required to complete a Family Volunteer Registration and submit the clearances as outlined. (Applications will only be accepted by our receptionist when all documents are complete and clearances attached.) Logos will issue a volunteer photo ID badge, and you will be required to wear this badge whenever volunteering. Option B: [Complete pages 1-3; return to front desk] I plan to volunteer (office, outside, or after school hours) will not have direct contact with children under 18 years of age. Option C: [Complete cover sheet only; return to front desk] I plan to donate one or a combination of the following needed school supplies, throughout the school year (donation must be equal to a $50 contribution): paper towels, tissues, and/or copy paper (20 pound, any color). Family Name(s): Relationship: Student Name(s): Grade(s): Visiting/ observing in student classrooms is not the same as volunteering. Our definition of volunteering implies direct contact with children under the age of 18, and clearances are required to volunteer in this capacity.

2 Family Volunteer Registration Form DATE NAME LAST FIRST MIDDLE STUDENT NAME(S) AND GRADE(S) PRESENT ADDRESS STREET (AREA CODE) TELEPHONE(S) CITY STATE ZIP CODE ADDRESS LIST THE WAYS IN WHICH YOU WOULD LIKE TO VOLUNTEER AT LOGOS: DATES AND TIMES AVAILABLE TO VOLUNTEER 1. DID YOU VOLUNTEER AT LOGOS DURING THE SCHOOL YEAR? YES NO 2. HAVE YOU OBTAINED CLEARANCES IN THE PAST 60 MONTHS (5 YEARS)? YES NO 3. IF YES, WERE THEY DONE THROUGH THE DEPARTMENT OF EDUCATION? YES NO IF YES TO ANY QUESTIONS 1-3, OUR FRONT DESK WILL PROVIDE YOU WITH AN ACT 24 FORM TO COMPLETE AND SIGN. 1

3 Volunteer Agreement I understand that I enter this Volunteer Program of my own free will, to serve without pay, understanding that I am not an employee or agent of Logos Academy and therefore I am not covered by any of its insurance programs or policies. I further agree to conduct myself in a professional manner, to promote the education and interest of the students and the reputation of Logos Academy. I understand and acknowledge that I am a mandated reporter with the meaning of the Child Protective Services Law. I understand that I am required by law to report instances of suspected child abuse. I have reviewed and understand District Policy 806, Child/Student Abuse, and materials found on the website keepkidssafe.pa.gov. I also understand that free online training is available from the Child Welfare Resource Center at _group_id=49_1. I understand Logos Academy has strongly encouraged me to complete this training. I acknowledge and agree that I will comply with Policy 806 and immediately report suspected child abuse as required by law. I also understand that any personal arrest or conviction must be reported to Logos Academy immediately using the enclosed ARREST/CONVICTION REPORT AND CERTIFICATION FORM (page 7), in accordance with Act 24 of 2011 and Act 82 of Signature: Date: Check List of Needed Items (Present to front desk) Family Volunteer Registration Form Completed Volunteer Agreement Signed Emergency Contact Information Completed Disclosure Statement Signed (If Applicable) FBI Criminal History Clearance Registration Number Obtained (If Applicable) Pa State Police Criminal Record Check Obtained and Original Attached Pa Child Abuse History Clearance Obtained and Original Attached Photo ID (For Verification) 2

4 EMERGENCY CONTACT INFORMATION Name: Home Phone: Cell Phone: PRIMARY EMERGENCY CONTACT Name: Relationship to Volunteer: Daytime Phone: Evening Phone: SECONDARY EMERGENCY CONTACT Name: Relationship to Volunteer: Daytime Phone: Evening Phone: PHYSICIAN Name: Group Name: Business Address: Phone Number: OTHER INFORMATION Allergies (Food, Insects, Etc.): Any other personal data you feel we should know in the event of a medical emergency: 3

5 LOGOS ACADEMY CLEARANCE PROCESS Instructions All volunteers must obtain a Child Abuse Clearance, Pennsylvania Criminal Clearance, and an FBI Federal Criminal History Clearance prior to volunteering at Logos Academy. Following are the instructions for obtaining the three required clearances: 1) FBI Federal Criminal History Clearance: Please Note: If you have lived in Pennsylvania 10 years or longer, you do not need to complete the FBI Federal Criminal History Clearance. You may complete the Disclosure Statement found on pages 5 and 6 of this registration form in place of the FBI check. A. Volunteers must register online ( and click PA Department of Education on the first screen). If you have any difficulties while registering online, call B. There is a fee of $27.00 for the fingerprint clearance. If you want to receive a copy of the fingerprint clearance, there is an additional $2.50 fee. Credit/debit card may be used online. Money order or cashier s check payable to Cogent Systems will be accepted. Cash or personal checks will not be accepted. C. Volunteers should either print out the registration confirmation number; or, if they do not have access to a printer, record the number in a safe place. D. Once registered, fingerprints can be taken at the location of your choice; no appointments are necessary. Please check the website for each location s hours. E. Volunteers must provide proof of identity upon arrival at the Fingerprint Center (state-issued driver's license, state I.D card, passport, etc.). F. After being fingerprinted, volunteers must provide the school with the registration confirmation number or original copy printed. Logos is unable to provide a copy of the clearance to the volunteer. 2) ACT 34- PA State Police Criminal Record Check A. Go to this clearance is free for volunteers. B. Verification will be obtained immediately. C. Volunteers MUST provide Logos with the original form. 3) Act 151- PA Child Abuse History Clearance A. Go to (create an account). B. After creating an account, you will receive an with your password in order to log into the website and complete the clearance application. C. Please be sure to select the appropriate type of clearance for educational institutions (School District). D. This clearance is free for volunteers. Verification can take up to 14 days; and volunteers can choose to receive notification via , mailed to their home address, or both. E. Once received, volunteers must provide Logos with the original clearance form. 4

6 DISCLOSURE STATEMENT Required by the Child Protective Service Law 23 Pa. C.S. Section (relating to volunteers having contact with children) I swear/affirm that I am seeking a volunteer position and AM NOT required to obtain a clearance through the Federal Bureau of Investigation, 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 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. Chapter 25 Section 2702 Section 2709 Section 2901 Section 2902 Section 3121 Section Section 3123 Section Section 3125 Section 3126 Section 3127 Section 4302 Section 4303 Section 4304 Section 4305 Section 5902(b) Section 5903(c) (d) Section 6301 Section 6312 (relating to criminal homicide) (relating to aggravated assault) (relating to stalking) (relating to kidnapping) (relating to unlawful restraint) (relating to rape) (relating to statutory sexual assault) (relating to involuntary deviate sexual intercourse) (relating to sexual assault) (relating to aggravated indecent assault) (relating to indecent assault) (relating to indecent exposure) (relating to incest) (relating to concealing death of child) (relating to endangering welfare of children) (relating to dealing in infant children) (relating to prostitution and related offenses) (relating to obscene and other sexual material and performances) (relating to corruption of minors) (relating to sexual abuse of children), or an equivalent crime under Federal law or the law of another state. I have not been convicted of a felony offense under Act (relating to the controlled substance, drug device and cosmetic act) committed within the past five years. 5

7 I understand that I shall not be approved for service if I am named as 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 person responsible for employment decisions or 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 for 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 person responsible for employment decisions or administrator of a program, activity or service shall immediately require me to submit current clearances obtained through the Department of Human Services, the Pennsylvania State Police, and the Federal Bureau of Investigation, as appropriate. The cost of clearances shall be borne by the employing entity or program, activity or service. I understand that if I willfully fail to disclose information required above, I commit a misdemeanor of the third degree and shall be subject to discipline up to and including denial of a volunteer position. I understand that the person responsible for employment decisions or the administrator of a program, activity or service is required to maintain a copy of my clearances. 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. Name: Signature: Witness: Signature: Date: 6

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