GIRL SCOUTS WESTERN PENNSYLVANIA
Volunteer Affidavit Regarding Pennsylvania Act 153 Compliance
I, the undersigned, swear and affirm the following statements of fact:
1. I am applying for the opportunity to serve as an unpaid volunteer for the Girl Scouts Western Pennsylvania
(GSWPA);
2. CHECK ONLY THE ONE (a or b) WHICH APPLIES TO YOU:
a.) I have been a resident of the Commonwealth of Pennsylvania during the entirety of the ten-year period
preceding the date of this Affidavit;
1. I am not disqualified from service as an unpaid volunteer for GSWPA pursuant to 23 Pa.C.S.A. §6344(c),
a copy of which is attached hereto, and have not been convicted of offenses of a similar nature to those
crimes listed therein 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.
2. The commencement of my volunteer service is contingent upon me obtaining and submitting to GSWPA
my 1.) criminal history record information from the Pennsylvania State Police and 2.) a certification from
the Pennsylvania Department of Human Services regarding my status as a perpetrator of child abuse,
pursuant to 23 Pa.C.S.A. §6344(b), and my subsequent approval for service from the organization.
b.) I have NOT been a resident of the Commonwealth of Pennsylvania during the entirety of the ten-year
period preceding the date of this Affidavit;
1. The commencement of my volunteer service is contingent upon me obtaining and submitting to GSWPA
my 1.) criminal history record information from the Pennsylvania State Police, 2.) a certification from the
Pennsylvania Department of Human Services regarding my status as a perpetrator of child abuse and 3.) a
Federal Bureau of Investigation (FBI) Criminal Background Check, pursuant to 23 Pa.C.S.A. §6344(b),
and my subsequent approval for service from the organization.
3. I understand that I am required to obtain and submit the reports referenced in the above paragraph every 36 months,
and that failure to do so will result in revocation of my approval as an unpaid volunteer.
4. I understand that if, while I am an approved unpaid volunteer, I am arrested or convicted of an offense that would
disqualify me from serving as an unpaid volunteer, or named as a perpetrator in a founded or indicated report of
child abuse, I must provide the Volunteer Screening Department of GSWPA with written notification of such an
arrest, conviction, or notification of perpetrator status within 72 hours of the arrest, conviction or notification,
pursuant to 23 Pa.C.S.A. §6344.3 (g).
I swear and affirm that the foregoing facts are true and correct. I also swear and affirm that if the facts I swear
to on this form become incorrect, I will immediately notify GSWPA. I understand that providing false information
will result in revocation of approval of my volunteer status.
Pursuant to 28 U.S.C. § 1746, I declare under penalty of perjury that the foregoing is true and correct.
Executed this ______ day of _____________________, 2015 .
(Volunteer Signature)
(Print or Type Name)
OVER
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