Child Abuse Disclosure Statement - Lower Susquehanna Synod - lss-elca 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your full name in the designated field. Ensure that you also include any other names you have been known by in the past five years.
3. Fill in your date of birth and Social Security Number accurately to maintain compliance with privacy regulations.
4. Provide your current address, including city, state, and ZIP code, followed by your current phone number (home, work, or cell).
5. Complete the driver’s license section by entering your license number, state of issuance, and expiration date.
6. Respond to the questions regarding any accusations or convictions related to crimes against minors. Circle 'YES' or 'NO' as applicable.
7. If applicable, provide explanations for any affirmative answers in the space provided.
8. Review all sections for accuracy before signing and dating the form at the bottom. If under 18, ensure a parent or guardian signs as well.

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