2. Unless indicated by my checking the “YES” box next to an item below, I have checked the “NO” box to indicate that neither I nor any other member of my household have a history of violent or abusive conduct including the following:
Check YES to all that applyCheck NO to all that DO NOT applySelfOther household memberDate
YES|NOA finding of abuse by a Children & Youth Agency or similar agency in Pennsylvania or similar statute in another jurisdiction
YES|NO|Abusive conduct as defined under the Protection from Abuse Act in Pennsylvania or similar statute in another jurisdiction
YES|NO|Other:
YES□
NO□
□
□
□
YES□
NO□
□
Other:
□
YES□
NO□
□
Please list any evaluation, counseling or other treatment received following conviction or finding of abuse:
If any conviction above applies to a household member, not a party, state that person's name, date of birth, and relationship to the child:
If you are aware that the other party or members of the other party’s household has or have a criminal record/abuse history, please explain: