Fillable Child-Abuse-Waiver Consent/Release Of Info Authorization Form Fo PA Child Abuse History Certification (Wilkes University)

Fill Online, Printable, Fillable, Blank Child-Abuse-Waiver Consent/Release Of Info Authorization Form Fo PA Child Abuse History Certification (Wilkes University) Form

Use Fill to complete blank online WILKES UNIVERSITY pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Child-Abuse-Waiver Consent/Release Of Info Authorization Form Fo PA Child Abuse History Certification (Wilkes University)

On average this form takes 3 minutes to complete

The Child-Abuse-Waiver Consent/Release Of Info Authorization Form Fo PA Child Abuse History Certification (Wilkes University) form is 2 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 12 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Wilkes University

BROWSE WILKES UNIVERSITY FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
CHILDLINE AND ABUSE REGISTRY
P.O. BOX 8170
HARRISBURG, PENNSYLVANIA 17105-8170
CONSENT/RELEASE OF INFORMATION AUTHORIZATION FORM
FOR THE PENNSYLVANIA CHILD ABUSE HISTORY CERTIFICATION
I, ( _______________________________ ), hereby authorize the PA Department of Human Sevices, ChildLine to
Applicant’s Name
release my Pennsylvania Child Abuse History Clearance information directly to ( _______________________________ ).
Name of Requesting Agency
I understand that this information is condential in nature pursuant to §6339 (relating to information in condential reports)
of the Child Protective Services Law (CPSL) (23 Pa.C.S Chapter 63) and is not otherwise to be released by
( _______________________________ ) without my expressed authorization or pursuant to Section 3490.126 of
Name of Requesting Agency
Title 55 of the Pennsylvania Code which states this information is condential and the requesting agency can be held
criminally liable for a breach of condentiality related to release of this information. I also understand that the
aforementioned information will not be released directly to me ( _______________________________ ) as stated
Applicant’s Name
on the Pennsylvania Child Abuse History Certication application. I understand that I will not receive a copy
of my Pennsylvania Child Abuse History Certication directly from ChildLine; however, I may request a copy of
my Pennsylvania Child Abuse History Certication from ( _______________________________ ) upon written request.
Name of Requesting Agency
I have read this Consent/Release of Information Authorization form and fully understand and agree to its content. I further
understand and agree to all information and ramications of the Pennsylvania Child Abuse History Certication application
as it otherwise relates to this consent. Further I understand that if I am listed in the statewide database for child abuse
that my consent allows the result stating such information to be shared with the agency/organization noted on next page.
Page 1 of 2
CY 999 3/16
Wilkes University
Wilkes University
Wilkes University
Please send my certication result(s) to:
Agency Name:
Agency Street Address:
Agency City, State, Zip Code:
Date Applicant’s Signature
As the agency/organization representative, I understand that, except for the subject of a report,
persons who receive this information are subject to the condentiality provisions of the CPSL
and 55 Pa. Code, Chapter 3490 and are required to ensure the condentiality and security
of the information and are liable for civil and criminal penalties for releasing information
to persons who are not permitted access to this information. I agree to receive and maintain
this information in accordance with these requirements.
Date
Agency’s Representative Signature
NOTE: IF THE PENNSYLVANIA CHILD ABUSE HISTORY CERTIFICATION FORM/APPLICATION (CY 113) IS NOT COMPLETED ACCURATELY
OR IF IT IS INCOMPLETE, THE CY 113 WILL BE RETURNED TO THE APPLICANT AND NOT BACK TO A THIRD PARTY.
Revised 12-29-15
Page 2 of 2
CY 999 3/16
Wilkes University c/o Gayle Patterson
84 West South Street
Wilkes-Barre, PA 18766
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Child-Abuse-Waiver ConsentRelease Of Info Authorization Form Fo PA Child Abuse History Certification (Wilkes University)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 27 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document