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Intro

Please describe any disorders, medical conditions or injuries that may impact your ability to manage the physical and/or emotional demands of working in equine assisted activities. Volunteer responsibilities may include communicating with others, following directions, working independently, walking for extended periods of time, jogging short distances, working in hot/humid/cold conditions, working with clients who may have mild to severe mental and/or physical challenges, and working with large animals.

Disclosure Statement

I hereby affirm that the information I provide is true and correct. I further affirm that in the event
that 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, or am named
as a perpetrator in a founded or indicated report, I must provide written notice to FHTRC no 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 failure to disclose this information is a misdemeanor and
shall be subject to discipline up to and including termination or denial of volunteer/ employed position.

Disclosure Statement Signature

To sign this form, please enter your name and today's date.

Background Check

Adults applying for or holding an unpaid position as a volunteer with a child care service, school, program, activity, or service responsible for a child’s welfare or having direct volunteer contact with children will need clearances. All prospective volunteers must obtain the following clearances:

  • 1. Report of criminal history from the Pennsylvania State Police (PSP); and
  • 2. Child Abuse History Clearance from the Department of Human Services (Child Abuse).
Additionally, a fingerprint based federal criminal history (FBI) submitted through the Pennsylvania State Police or its authorized agent is required if the volunteer has lived outside the Commonwealth of Pennsylvania in the last 10 years.

If the volunteer is not required to obtain clearances, they must swear or affirm in writing that they are not disqualified from service based upon a conviction of an offense under §6344.
Clearances can be obtained at: www.KeepKidsSafe.pa.gov

Background Check Signature

To sign this form, please enter your name and today's date.