APPLICANT CONSENT TO SERVE AND 
ADHERE TO PROTOCOL AND PROCEDURE

EVERYONE MUST READ AND AGREE TO THE ENTIRE STATEMENT BELOW BEFORE YOU MAY CONTINUE

I am voluntarily participating in the volunteer activities with knowledge of the danger involved and I agree to accept all known and unknown forms of personal risk, liability and responsibility  resulting from my participation in perpetuity. I also agree to indemnify and hold harmless the WNUZ-LP, it’s agents, affiliated networks, network affiliates, donors, underwriters, management, station F.C.C. licensee, operators, other station volunteers (past or present) and the affiliates of any of the aforementioned or parties identified by the founder or organization president of any and all claims of which may arise as result of my participation in the volunteer activities under the authority of the General Manager of WNUZ-LP, endorsed by the President of WLRI Incorporated in perpetuity.

DISCLOSURE STATEMENT APPLICATION FOR VOLUNTEERS
Required by the Pennsylvania Child Protective Service Law
23 Pa. C.S. Section 6344.2 (relating to volunteers having contact with children)

I swear/affirm that I am seeking a volunteer position and AM NOT required to obtain a certification
through the Federal Bureau of Investigation (FBI), 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 understand that if I have not been a resident of Pennsylvania during the entirety of the pervious ten-year
period, but have received certification from the FBI since establishing residency, I must provide a copy of
the certification to my employer and am not required to obtain any additional FBI certifications.
I swear/affirm that, if providing certifications that have been obtained within the preceding 60 months, I
have not been disqualified from service as outlined below or have not been convicted of an offense similar
in nature to a crime listed below 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 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 statutes 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 (relating to criminal homicide)
Section 2702 (relating to aggravated assault)
Section 2709.1 (relating to stalking)
Section 2901 (relating to kidnapping)
Section 2902 (relating to unlawful restraint)
Section 3121 (relating to rape)
Section 3122.1 (relating to statutory sexual assault)
Section 3123 (relating to involuntary deviate sexual intercourse)
Section 3124.1 (relating to sexual assault)
Section 3125 (relating to aggravated indecent assault)
Section 3126 (relating to indecent assault)
Section 3127 (relating to indecent exposure)
Section 4302 (relating to incest)
Section 4303 (relating to concealing death of child)
Section 4304 (relating to endangering welfare of children)
Section 4305 (relating to dealing in infant children)
Section 5902(b) (relating to prostitution and related offenses)
Section 5903(c) (d) (relating to obscene and other sexual material and performances)
Section 6301 (relating to corruption of minors)
Section 6312 (relating to sexual abuse of children), or an equivalent crime under
Federal law or the law of another state.
211/3/15

I swear/affirm that I have not been convicted of a felony offense under Act 64-1972 (relating to the
controlled substance, drug device and cosmetic act) committed within the past five years.

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 certifications obtained through the
Department of Human Services, the Pennsylvania State Police, and the Federal Bureau of Investigation, as
appropriate. The cost of certifications 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 certifications obtained for the volunteering purposes can only be used for that purpose and
cannot be used for employment purposes.

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 certifications.

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.

AFTER READING THE ABOVE STATEMENTS I AFFIRM THAT I COMPLY WITH CURRENT PENNSYLVANIA AND UNITED STATES CODE APPLICABALE TO VOLUNTEERS IN PENNSYLVANIA. I WILL INDICATE MY COMPLICANCE ON THIS FORM BY PROVIDING MY FULL NAME AND ADDRESS ON MY CURRENT VALID PENNSYLVANIA IDENTIFICATION CARD (PA DRIVER’S LICENSE) OR VALID AND CURRENT U.S. PASSPORT OR VALID AND CURRENT U.S. GOVERNMENT OR VALID AND CURRENT MILITARY IDENTIFICATION BELOW.

AFTER YOU PRESS SUBMIT – KEEP WATCHING THE SCREEN WHERE THIS FORM IS FOR A STATUS UPDATE TO CONFIRM THAT THE APPLICATION WAS SENT TO US. THEN MOVE ON TO THE NEXT QUESTION BELOW.

CLICK SUBMIT AND JUST WAIT HERE FOR CONFIRMATION – DON’T GO BACK OR EXIT UNTIL YOU CAN SEE CONFIRMATION ABOVE THAT YOUR INFORMATION WAS SENT.

THEN, YOU CAN CLICK THE LINK BELOW TO START YOUR APPLICATION-

PROBLEMS? QUESTIONS? Please contact “operations at WNUZ . org” from your e-mail.

ALL INFORMATION OBTAINED IS PRIVATE AS OUTLINED IN OUR PRIVACY POLICY

Click Here Start Your WNUZ Volunteer Application 

WNUZ WILL MAKE EVERY ATTEMPT TO ACCOMIDATE EVERYONE WITH AN APPLICATION THAT ACCOMIDATES THEIR SPECIFIC HEALTH OR LANGUAGE NEEDS. AVAILABLE UPON REQUEST HERE.