APPENDIX D – SCREENING RENEWAL FORM

NAME: (First Middle Last)
________________________________________________________________

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

________________________________________________________________

DATE OF BIRTH: (Month/ Day/ Year) _______________________
GENDER IDENTITY: __________

EMAIL: __________________ PHONE: _____________________

By signing this document below, I certify that there have been no changes to my criminal record since I last submitted an Enhanced Police Information Check and/or Vulnerable Sector Check and/or Screening Disclosure Form to the Canadian Blind Sports Association or to the Participating Member. I further certify that there are no outstanding charges and warrants, judicial orders, peace bonds, probation or prohibition orders, or applicable non-conviction information, and there have been no absolute and conditional discharges.

I agree that any Enhanced Police Information Check and/or Vulnerable Sector Check and/or Screening Disclosure Form that I would obtain or submit on the date indicated below would be no different than the last Enhanced Police Information Check and/or Vulnerable Sector Check and/or Screening Disclosure Form that I submitted to the Canadian Blind Sports Association or the Participating Member. I understand that if there have been any changes, or if I suspect that there have been any changes, it is my responsibility to obtain and submit a new Enhanced Police Information Check and/or Vulnerable Sector Check and/or Screening Disclosure Form to the Screening Committee instead of this form.

I recognize that if there have been changes to the results available from the Enhanced Police Information Check and/or Vulnerable Sector Check and/or Screening Disclosure Form, and that if I submit this form improperly, then I am subject to disciplinary action and/or the removal of volunteer responsibilities or other privileges at the discretion of the Screening Committee.

NAME (print): ____________________ DATE: ______________________

SIGNATURE: _________________________