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Pennsylvania Regional Citizen Review Panels Application

2024

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Eligibility

To be eligible to join the Pennsylvania Regional Citizen Review Panels, you must meet the following criteria:

You live or work in the Northwest Region (Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Forest, Jefferson, McKean, Mercer, Venango, or Warren County);
You are willing to go through the necessary steps to obtain and provide copies of the Department of Human Services Child Abuse Clearances, Pennsylvania State Police Criminal Record Checks, and FBI child abuse clearances;
You DO NOT currently work for the PA Department of Human Services or a County Children and Youth Agency; and
You DO NOT have an open/active case with a County Children and Youth Agency.

Contact Information

First name:*

Middle initial:

Last name:*

Home Address: (Home address is required to establish county of residency)

Street:*

City/Town:*

State:*

County:*

Zip code:*

Phone:*

Email:*

Preferred method of contact for follow-up:*

Background Information

Have you ever been employed by the PA Department of Human Services or a County Children and Youth Agency? *

If yes, where, start/end date of employment, and in what capacity?*

Are you currently employed?*

County:*

Which of the following system partners have you worked for/with (select all that apply):

Child Protective Services

Community Services

Court Appointed Special Advocates

Drug and Alchohol Services

Education

Foster Care/Parent

Juvenile Probation

Mental Health/Intellectual and Developmental Disabilities Services

Physical Health

None

Other

Please explain:*

What additional personal or professional experiences do you have with the child welfare system?*

Interest

Where did you hear about the citizen review panel (please be as specific as possible)?*

Did you receive an email from a listserv?*

Yes

If yes, which listserv?*

Did you receive a referral to join?*

Yes

If so, from whom?*

Why are you interested in joining a PA Regional Citizen Review Panel?*

What do you hope to get out of the experience?*

Committment

Are you willing to serve a five-year term on the panel?*

Yes

Can you commit to attending a minimum of six meetings per year (quarterly regional meetings and two all-panel meetings)? *

Yes

Do you have any reservations about serving as a volunteer panel member?*

Yes

If yes, explain:*

References

Please list the name, complete address including zip code, email address, and daytime phone number of three non-relatives.

Reference 1

Name:

Address:

City:

State:

Zip:

Phone:

Email:

Relationship:

Reference 2

Name:

Address:

City:

State:

Zip:

Phone:

Email:

Relationship:

Reference 3

Name:

Address:

City:

State:

Zip:

Phone

Email:

Relationship:

E-Signature:

Clear

Date