Child Participation Form – Form 3/11 Which Daycare is this for? Jet’s Daycare Ity Bity Learning Center J & L Learning Academy CHILD CARE ATTESTATION OF GOOD MORAL CHARACTERState of Florida County of I, First who, as an applicant for employment with, an employee of, a volunteer for, or an applicant to volunteer with I affirm and attest under penalty of perjury that I meet the moral character requirements for employment, as required by Chapter 435 Florida Statutes in that: , I affirm and attest under penalty of perjury that I meet the moral character requirements for employment, as required by Chapter 435 Florida Statutes in that: Section 393.135 sexual misconduct with certain developmentally disabled clients and reporting of such sexual misconduct Section 394.4593 sexual misconduct with certain mental health patients and reporting of such sexual misconduct Section 415.111 adult abuse, neglect, or exploitation of aged persons or disabled adults or failure to report of such abuse Section 741.28 criminal offenses that constitute domestic violence, whether committed in Florida or another jurisdiction Section 777.04 attempts, solicitation, and conspiracy Section 782.04 murder Section 782.07 manslaughter, aggravated manslaughter of an elderly person or disabled adult, or aggravated manslaughter of a child Section 782.071 vehicular homicide Section 782.09 killing an unborn quick child by injury to the mother Chapter 784 assault, battery, and culpable negligence, if the offense was a felony Section 784.011 assault, if the victim of offense was a minor Section 784.03 battery, if the victim of offense was a minor Section 787.01 kidnapping Section 787.02 false imprisonment Section 787.025 luring or enticing a child Section 787.04(2) taking, enticing, or removing a child beyond the state limits with criminal intent pending custody proceeding Section 787.04(3) carrying a child beyond the state lines with criminal intent to avoid producing a child at a custody hearing or delivering the child to the designated person Section 790.115(1) exhibiting firearms or weapons within 1,000 feet of a school Section 790.115(2) (b) possessing an electric weapon or device, destructive device, or other weapon on school property Section 794.011 sexual battery Former Section 794.041 prohibited acts of persons in familial or custodial authority Section 794.05 unlawful sexual activity with certain minors Chapter 796 prostitution Section 798.02 lewd and lascivious behavior Chapter 800 lewdness and indecent exposure Section 806.01 arson Section 810.02 burglary Section 810.14 voyeurism, if the offense is a felony Section 810.145 video voyeurism, if the offense is a felony Chapter 812 theft and/or robbery and related crimes, if a felony offense Section 817.563 fraudulent sale of controlled substances, if the offense was a felony Section 825.102 abuse, aggravated abuse, or neglect of an elderly person or disabled adult Section 825.1025 lewd or lascivious offenses committed upon or in the presence of an elderly person or disabled adult Section 825.103 exploitation of disabled adults or elderly persons, if the offense was a felony Section 826.04 incest Section 827.03 child abuse, aggravated child abuse, or neglect of a child Section 827.04 contributing to the delinquency or dependency of a child Former Section 827.05 negligent treatment of children Section 827.071 sexual performance by a child Section 843.01 resisting arrest with violence Section 843.025 depriving a law enforcement, correctional, or correctional probation officer means of protection or communication Section 843.12 aiding in an escape Section 843.13 aiding in the escape of juvenile inmates in correctional institution Chapter 847 obscene literature Section 874.05 encouraging or recruiting another to join a criminal gang Chapter 893 drug abuse prevention and control only if the offense was a felony or if any other person involved in the offense was a minor Section 916.1075 sexual misconduct with certain forensic clients and reporting of such sexual conduct Section 944.35(3) inflicting cruel or inhuman treatment on an inmate resulting in great bodily harm Section 944.40 escape Section 944.46 harboring, concealing, or aiding an escaped prisoner Section 944.47 introduction of contraband into a correctional facility Section 985.701 sexual misconduct in juvenile justice programs Section 985.711 contraband introduced into detention facilitiesI understand that I must acknowledge the existence of any applicable criminal record relating to the above lists of offenses including those under any similar statute of another jurisdiction, regardless of whether or not those records have been sealed or expunged. Further, I understand that, while employed or volunteering atin any position that requires background screening as a condition of employment, I must immediately notify my supervisor/employer of any arrest and any changes in my criminal record involving any of the above listed provisions of Florida Statutes or similar statutes of another jurisdiction whether a misdemeanor or felony. This notice must be made within one business day of such arrest or charge. Failure to do so could be grounds for termination. First in any position that requires background screening as a condition of employment, I must immediately notify my supervisor/employer of any arrest and any changes in my criminal record involving any of the above listed provisions of Florida Statutes or similar statutes of another jurisdiction whether a misdemeanor or felony. This notice must be made within one business day of such arrest or charge. Failure to do so could be grounds for termination.I attest that I have read the above carefully and state that my attestation here is true and correct that my record does not contain any of the above listed offenses. I understand, under penalty of perjury, all employees in such positions of trust or responsibility shall attest to meeting the requirements for qualifying for employment and agreeing to inform the employer immediately if arrested for any of the disqualifying offenses. I also understand that it is my responsibility to obtain clarification on anything contained in this affidavit which I do not understand prior to signing. I am aware that any omissions, falsifications, misstatements or misrepresentations may disqualify me from employment consideration and, if I am hired, may be grounds for termination or denial of an exemption at a later date.SignatureDate MM slash DD slash YYYY Sign Above OR Below, DO NOT Sign Both LinesTo the best of my knowledge and belief, my record contains one or more of the applicable disqualifying acts or offenses listed above. I have placed a check mark by the offense(s) contained in my record. (If you have previously been granted an exemption for this disqualifying offense, please attach a copy of the letter granting such exemption.) (Please circle the number which corresponds to the offense(s) contained in your record.) SignatureDate MM slash DD slash YYYY In Witness Whereof, Employee has attested to Good Moral Character on this date MM slash DD slash YYYY SIGNATURE of Owner/Director:
