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Sworn Statement Pertaining to the Prior Conduct of a Pupil Seeking Admission for GCC 2018-19

Section 1304-A. of the Public School Code of 1949, as amended, and referenced in Section 4245 of the Diocese of Greensburg School Policies requires that prior to the admission of any student, the parent, guardian, or other person having control or charge of the student shall provide the following sworn statement or affirmation. I swear and affirm that the below information is true and correct. I understand that misrepresentation of the below data is a criminal act and punishable under the Pennsylvania Crimes Code.

Who will be signing?
Minor
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First Student Name

First Name*

Last Name*
First Student Date of Birth*
I certify that I am 18 years of age or older
First Student Signature*
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Has the student ever been suspended or expelled from any public or private school in Pennsylvania or in any other state?*
No
Yes
Did the suspension or expulsion involve weapons?*
No
Yes
Did the suspension or expulsion involve alcohol?*
No
Yes
Did the suspension or expulsion involve drugs?*
No
Yes
Did the suspension involve infliction of physical or emotional injury to another person? This includes hurting others through technology (cyberbullying, texting, etc.).*
No
Yes
Did the suspension or expulsion include any act of violence committed on school property, committed during a school event or an act of destruction to school property?*
No
Yes
Have you been arrested and/or have you been or are you on juvenile probation?*
No
Yes
If the answer to any above question is "YES," explain the incident and circumstances in detail including the school, date of suspension or expulsion, and a final decision regarding the incident.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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