Appendix C-Screening Disclosure Form

This form must be completed by any individual who wishes to work or volunteer for the Canadian Blind Sports Association (CBSA). In addition, they must re-submit this form every three years. It provides the organization with information about possible levels of risks to the organization as the result of past criminal or other activity.

NAME: (First, Middle, Last) ________________________________________________________________

OTHER NAMES YOU HAVE USED: __________________________________

CURRENT PERMANENT ADDRESS: (Street, City, Province, Postal Code)

________________________________________________________________

DATE OF BIRTH: (Month/Day/Year) _________________
GENDER IDENTITY: ____________

CLUB (if applicable): ________________
EMAIL: _____________________

Note: Failure to disclose truthful information below may be considered an intentional omission and the loss of volunteer responsibilities or other privileges

1. Have you been convicted of a crime? If so, please complete the following information for each conviction. Attach additional pages as necessary.

Name or Type of Offense: ___________________________________________

Name and Jurisdiction of Court/Tribunal: ________________________________

Year Convicted: ___________________________________________________

Penalty or Punishment Imposed: ______________________________________

Further Explanation: ________________________________________________

2. Have you ever been disciplined or sanctioned by a sport governing body or by an independent body (e.g., private tribunal, government agency, etc.) or dismissed from a coaching or volunteer position? If so, please complete the following information for each disciplinary action or sanction. Attach additional pages as necessary.

Name of disciplining or sanctioning body: _______________________________

Date of discipline, sanction or dismissal: ________________________________

Reasons for discipline, sanction or dismissal: ____________________________

Penalty or Punishment Imposed: ______________________________________

Further Explanation: ________________________________________________

3. Are criminal charges or any other sanctions, including those from a sport body, private tribunal or government agency, currently pending or threatened against you? If so, please complete the following information for each pending charge or sanction. Attach additional pages as necessary.

Name or Type of Offense: ___________________________________________

Name and Jurisdiction of Court/Tribunal: ________________________________

Name of disciplining or sanctioning body: _______________________________

Further Explanation: ________________________________________________

PRIVACY STATEMENT

By completing and submitting this Screening Disclosure Form, I consent and authorize the Canadian Blind Sports Association and/or the Participating Member to collect, use and disclose my personal information, including all information provided on the Screening Disclosure Form as well as my Enhanced Police Information Check and/or Vulnerable Sector Check (when permitted by law) for the purposes of screening, implementation of the Screening Policy, administering membership services, and communicating with National Sport Organizations, Provincial/Territorial/Multi Sport Organizations, Clubs, and other organizations involved in the governance of sport. The Canadian Blind Sports Association and its Participating Members do not distribute personal information for commercial purposes.

CERTIFICATION

I hereby certify that the information contained in this Screening Disclosure Form is accurate, correct, truthful and complete.

I further certify that I will immediately inform the Canadian Blind Sports Association or the Participating Member (as applicable) of any changes in circumstances that would alter my original responses to this Screening Disclosure Form. Failure to do so may result in the withdrawal of volunteer responsibilities or other privileges and/or disciplinary action.

NAME (print): ____________________________________________________

DATE: __________________________________________________________

SIGNATURE: _____________________________________________________