TEACHER EDUCATION DEPARTMENT
CRIMINAL HISTORY DISCLOSURE STATEMENT
AUTHORIZATION AND RELEASE
Student: _________________________________ Student ID No. ________________
Date: __________________
HCC Teacher Name _____________________________
Please read carefully.
As a prerequisite to the placement of education students in field experiences, the Code of
Maryland Regulations requires students to complete the following Criminal History Disclosure
Statement. Students are also required to update the information contained in this Disclosure
Statement based on any changes in, or additions to, their criminal history until the time they
graduate or otherwise cease their enrollment at Howard Community College.
**************************
Have you ever been convicted of, pled guilty or nolo contendere with respect to, or received
probation before judgment with respect to, a crime against children, in Maryland or any other
jurisdiction? As defined in Section 3-601 and 3-602 of the Criminal Law Article of the
Annotated Code of Maryland, a crime against children includes child abuse and sexual abuse of a
child (see attached). YOU NEED NOT PROVIDE ANY INFORMATION CONCERNING
CRIMINAL CHARGES AGAINST
HCC Teacher Name __________________
YOU THAT HAVE BEEN
EXPUNGED.
__________ No
___________ Yes
Have you ever been convicted of, pled guilty or nolo contendere with respect to, or received
probation before judgment with respect to, a crime of violence? Crimes of violence are defined
in Section 14-101 of the Criminal Law Article of the Annotated Code of Maryland (see
attached). YOU NEED NOT PROVIDE ANY INFORMATION CONCERNING
CRIMINAL CHARGES AGAINST YOU THAT HAVE BEEN EXPUNGED.
__________ No
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___________ Yes
If your answer to either of the preceding questions is yes, please explain fully on the back of this
page, specifying the nature and date of the offense(s), the name and location of the court(s) and
the disposition(s), or outcome(s), including the sentences(s) imposed, if any.
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I hereby declare and affirm under penalties of perjury that the contents of the foregoing
Disclosure Statement are true and correct and complete to the best of my knowledge, information
and belief. I understand that I am obligated, and that I hereby agree, to update the information
contained in the Disclosure Statement based on any changes in or additions to my criminal
history until such time that I graduate or otherwise cease my enrollment at Howard Community
College. I also understand that the failure fully and accurately to complete and update the
Disclosure Statement could result in action being taken against me, including removal from a
field placement and/or dismissal from Howard Community College.
I hereby authorize Howard Community College and their agents, employees and representatives
to investigate, utilize and disseminate the Disclosure Statement, and any information contained
therein or derived therefrom, for any and all purposes associated with my field placement and
with inquiries regarding my licensure or certification, and my employment, as a certified
education professional in the State of Maryland or any other jurisdiction.
I hereby release, discharge and exonerate Howard Community College and their agents,
employees and representatives from any and all liability, loss, claims and/or damages of every
nature and kind arising out of, or in any way related to, the Disclosure Statement, the information
contained therein or derived therefrom and the investigation, dissemination or use thereof.
Students must complete the Criminal Disclosure form and have it notarized. This can be
accomplished in two ways: Your HCC instructor will invite the HCC Notary to your class or
after two weeks, you may go to the Welcome and Information Center. This is a free service and
requires you to show your current HCC ID. This is a legal document. Any falsification of the
information on this document can result in suspension from all field experiences and would
constitute a violation of the Code of Conduct.
________________________________
Signature of Student
(Do not sign until instructed by Notary.)
_____________________________
Signature of Parent or Legal Guardian
if student is under age 18
________________________________
Printed Name of Student
_____________________________
Printed Name of Parent
Local Address: ____________________________________________________
____________________________________________________
Local phone Number: _______________________________________________
(Do not write below this line. To be completed by Notary)
STATE OF: ______________________________________________________
COUNTY OF: ____________________________________________________
Subscribed and sworn before me this __________ day of _______________, 2_____
_______________________________________
Notary Public
KEEP THE FOLLOWING PAGES FOR YOUR RECORDS
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§ 3-601. Child abuse.
Definitions. –
(1)
In this section the following words have the meanings indicated.
(2)
“Abuse” means physical injury sustained by a minor as a result of cruel or inhumane
treatment or as a result of a malicious act under circumstances that indicate that the minor’s health or
welfare is harmed or threatened by the treatment or act.
(3)
“Family member” means a relative of a minor by blood, adoption, or marriage.
(4)
“Household member” means a person who lives with or is a regular presence in a
home of a minor at the time of the alleged abuse.
(5)
“Severe physical injury” means:
(i)
brain injury or bleeding within the skull;
(ii)
starvation; or
(iii)
physical injury that:
1.
creates a substantial risk of death; or
2.
causes permanent or protracted serious:
A.
disfigurement;
B.
loss of the function of any bodily member or organ; or
C.
impairment of the function of any bodily member or organ.
(b)
First-degree child abuse. –
(1)
A parent or other person who has permanent or temporary care or custody or
responsibility for the supervision of a minor may not cause abuse to the minor that:
(i)
results in the death of the minor; or
(ii)
causes severe physical injury to the minor
(2)
Except as provided in subsection (c) of this section, a person who violates paragraph
(1) of this subsection is guilty of the felony of child abuse in the first degree and on conviction is
subject to:
(i)
imprisonment not exceeding 25 years; or
(ii)
if the violation results in the death of the victim, imprisonment not exceeding
30 years.
(c)
Repeated offense. – A person who violates this section after being convicted of a previous
violation of this section is guilty of a felony and on conviction is subject to:
(1)
imprisonment not exceeding 25 years; or
(2)
if the violation results in the death of the victim, imprisonment not exceeding 30
years.
(d)
Second-degree child abuse. –
(1)
(i)
A parent or other person who has permanent or temporary care or custody or
responsibility for the supervision of a minor may not cause abuse to the minor.
(ii)
A household member or family member may not cause abuse to a minor.
(2)
Except as provided in subsection (c) of this section, a person who violates paragraph
(1) of this subsection is guilty of the felony of child abuse in the second degree and on conviction is
subject to imprisonment not exceeding 15 years.
(e)
Sentencing. – A sentence imposed under this section may be separate from and consecutive
to or concurrent with a sentence for any crime based on the act establishing the violation of this
section. (An. Code 1957, art. 27, § 35C(a)(1), (2), (4)-(6), (b); 2002, ch. 26, § 2; ch. 273, § 2; 2003,
ch. 167.)
(a)
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§ 3-602. Sexual abuse of a minor.
Definitions. –
(1)
In this section the following words have the meanings indicated.
(2)
“Family member” has the meaning stated in § 3-601 of this subtitle.
(3)
“Household member” has the meaning stated in § 3-601 of this subtitle.
(4)
(i)
“Sexual abuse” means an act that involves sexual molestation or
exploitation of a minor, whether physical injuries are sustained or not.
(ii)
“Sexual abuse” includes:
1.
incest;
2.
rape;
3.
sexual offense in any degree;
4.
sodomy; and
5.
unnatural or perverted sexual practices.
(b)
Prohibited. –
(1)
A parent or other person who has permanent or temporary care or custody or
responsibility for the supervision of a minor may not cause sexual abuse to the minor.
(2)
A household member or family member may not cause sexual abuse to a minor.
(c)
Penalty. – A person who violates this section is guilty of a felony and on conviction is
subject to imprisonment not exceeding 25 years.
(d)
Sentencing. – A sentence imposed under this section may be separate from and
consecutive to or concurrent with a sentence for:
(1)
any crime based on the act establishing the violation of this section; or
(2)
a violation of § 3-601 of this subtitle involving an act of abuse separate from
sexual abuse under this section. (2002, ch. 273, § 2; 2003, ch. 167.)
(a)
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§ 14-101. Mandatory sentences for crimes of violence.
(a)
“Crime of violence” defined. - In this section, “crime of violence” means:
(1)
abduction;
(2)
arson in the first degree;
(3)
kidnapping;
(4)
manslaughter, except involuntary manslaughter;
(5)
mayhem;
(6)
maiming, as previously proscribed under former Article 27, §§ 385 and 386 of the
Code;
(7)
(8)
(9)
(10)
(11)
(12)
(13)
(14)
(15)
subsection;
(16)
(17)
(18)
(19)
(20)
(21)
murder;
rape;
robbery under § 3-402 or § 3-403 of this article;
carjacking;
armed carjacking;
sexual offense in the first degree;
sexual offense in the second degree;
use of a handgun in the commission of a felony or other crime of violence;
an attempt to commit any of the crimes described in items (1) through (14) of this
assault in the first degree;
assault with intent to murder;
assault with intent to rape;
assault with intent to rob;
assault with intent to commit a sexual offense in the first degree; and
assault with intent to commit a sexual offense in the second degree.
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