One College Drive
Calais, ME 04619
Admissions Office 207-454-1000
: Washington County Community College is an equal opportunity/affirmative action institution and employer.
For more information; please call Tatiana Osmond, Affirmative Action Officer, at 454-1040.
AD – Form Disclosure of Criminal Convictions; Revised: July 8, 2019; amd
Student Disclosure of Criminal Convictions,
Pending Criminal Charges and Certain Disqualifications
Please read, complete carefully and return immediately to the address provided on the form. If you need advice to determine whether
you can benefit from enrolling in your desired program at WCCC, contact Enrollment Services at 454-1000 to arrange a meeting with
the Dean of Enrollment Management & Students.
Requirement to Disclose
The College requires you to complete the accompanying Student Disclosure of Criminal Convictions, Pending Criminal Charges and
Certain Disqualifications form (“Form”) because at least one clinical/field site where enrolled students are placed for practicum(s),
externship(s) or field placement(s) require(s) the College to do so.
College Use of the Information Disclosed
Your answers on this Form will be used to determine whether the clinical site will accept your placement. The existence of a
conviction, pending charge or other disqualification does not necessarily mean that you will be denied admission to a site. The site
will evaluate each case on its own facts, looking at the nature, severity, recency of the crime, charge or disqualification, as well as the
interests and needs of the site.
Full Disclosure Required
You must complete this Form to the best of your ability. This means that your answers must be truthful, accurate and complete. If you
know of certain information yet are unsure whether to disclose it, you must disclose the information. The site will later determine
whether the disclosure was required and, if so, whether the information is material.
Consequence of Failure to Disclose
By your signature on the Form, you certify that you understand and agree that your failure to disclose material information on the
Form may result in immediate exclusion, suspension or expulsion from the site or the College.
Continuing Duty to Disclose
By your signature on the Form, you also certify that you understand and agree that you will notify the College immediately of any
inaccuracies in, or corrections to, the information you disclose there. You also certify that you understand and agree that you have a
continuing duty to notify the College of any conviction, charge or disqualification after you have completed this Form and until you
have completed all of your practicums.
For purposes of this Form, the following terms have the following meanings.
“Pending criminal charge” means any charge that is currently pending or threatened to be brought against you.
“Criminal conviction” means any instance in any state or country where you have pleaded no contest, guilty or were found to be
guilty by a judge or jury to charges that you committed a crime, other than those excluded below. “Criminal conviction” does
1. conviction that you are currently appealing; and
2. juvenile conviction, a conviction for which the record has been expunged and/or a conviction for which you have received a
pardon, unless the law of the state where such juvenile conviction, expungement or pardon expressly permits you to lawfully
withhold its disclosure.
“Criminal conviction” does not include, and therefore you need not disclose, any instance where you were:
1. arrested but not charged;
2. arrested and charged but the charges were dropped;
3. arrested and charged but found not guilty by a judge or jury;
4. arrested, found guilty by a judge or jury but the conviction was overturned on appeal; and
5. any traffic offense for which your penalty was a fine of less than $200.
“Disqualification” means any occasion that resulted in your removal or exclusion from any health care facility due to an allegation
that you engaged in a form of neglect or other misconduct.