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1. I HEREBY RELEASE AND DISCHARGE THE HAMILTON POLICE SERVICE AND THE HAMILTON POLICE SERVICES BOARD AND ALL MEMBERS AND
EMPLOYEES OF THE SAID BOARD FROM ANY AND ALL ACTIONS, CLAIMS AND DEMANDS FOR DAMAGES, LOSS OR INJURY HOWSOEVER ARISING WHICH
MAY HEREAFTER BE SUSTAINED BY MYSELF AS A RESULT OF THE DISCLOSURE OF INFORMATION BY THE MEMBER OF THE POLICE SERVICE. I HEREBY
AUTHORIZE THE HAMILTON POLICE SERVICE TO INQUIRE INTO AND DISCLOSE THE RESULTS OF ANY POLICE RECORDS INDICATING CRIMINAL
CONVICTIONS, CONDITIONAL AND ABSOLUTE DISCHARGES, OUTSTANDING CRIMINAL CHARGES TO ME AND TO CONDUCT A LOCAL POLICE CONTACT
SEARCH WITH ANY POLICE SERVICE IN CANADA.
2. I CERTIFY THAT THE INFORMATION PROVIDED BY ME IN THIS APPLICATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND
BELIEF. I HAVE READ THIS CONSENT, UNDERSTAND IT AND AGREE TO IT IN ITS ENTIRETY.
3. I UNDERSTAND THAT THE PRESCRIBED FEE IS NON-REFUNDABLE.
Applicant’s Name | please print Applicant’s Signature
Section C | To be completed by applicants applying for a position with a government agency (Federal,
Provincial or Municipal)
Name of Government Agency
Address of Government Agency
Position with Government Agency
Section D | Vulnerable Sector Check To be completed by Applicant
THIS SECTION IS RESTRICTED TO APPLICANTS SEEKING EMPLOYMENT AND/OR VOLUNTEERING WITH VULNERABLE INDIVIDUALS.
A Vulnerable Sector check is required when a position (paid or volunteer) is one of authority and trust relative to children or vulnerable persons:
A “CHILD” MEANS A PERSON UNDER THE AGE OF 18.
“VULNERABLE PERSONS" MEANS PERSONS WHO, BECAUSE OF THEIR AGE, A DISABILITY OR OTHER CIRCUMSTANCES, WHETHER TEMPORARY OR
PERMANENT, (A) ARE IN A POSITION OF DEPENDENCE ON OTHERS; OR (B) ARE OTHERWISE AT A GREATER RISK THAN THE GENERAL POPULATION OF
BEING HARMED BY PERSONS IN A POSITION OF AUTHORITY OR TRUST RELATIVE TO THEM.
Casual or occasional contact with children or other vulnerable persons do not normally require a Vulnerable Sector check unless the position could lead the
organization’s clients to have trust in the individual.
PART 1 | Reason for Consent fill out the following
I AM AN APPLICANT FOR A PAID OR VOLUNTEER POSITION WITH A PERSON OR ORGANIZATION RESPONSIBLE FOR THE WELL-BEING OF ONE OR MORE
CHILDREN OR VULNERABLE PERSONS.
Name of person or organization
Description of the paid or volunteer position
Details regarding the responsibilities towards the child(ren) or vulnerable person(s)
PART 2 | Consent
I HEREBY CONSENT TO A SEARCH BEING MADE IN THE AUTOMATED CRIMINAL RECORDS RETRIEVAL SYSTEM MAINTAINED BY THE ROYAL CANADIAN
MOUNTED POLICE TO FIND OUT IF I HAVE BEEN CONVICTED OF, AND BEEN GRANTED A RECORD SUSPENSION FOR, ANY OF THE SEXUAL OFFENCES THAT
ARE LISTED IN THE SCHEDULE TO THE CRIMINAL RECORDS ACT.
I UNDERSTAND THAT, AS A RESULT OF GIVING THIS CONSENT, IF I AM SUSPECTED OF BEING THE PERSON NAMED IN A CRIMINAL RECORD FOR ONE OF
THE SEXUAL OFFENCES LISTED IN THE SCHEDULE TO THE CRIMINAL RECORDS ACT IN RESPECT OF WHICH A RECORD SUSPENSION WAS GRANTED OR
ISSUED, I WILL BE REQUESTED TO PROVIDE FINGERPRINTS TO CONFIRM THAT RECORD AND THAT RECORD MAY BE PROVIDED BY THE COMMISSIONER
OF THE ROYAL CANADIAN MOUNTED POLICE TO THE MINISTER OF PUBLIC SAFETY AND EMERGENCY PREPAREDNESS, WHO MAY THEN DISCLOSE ALL OR
PART OF THE INFORMATION CONTAINED IN THAT RECORD TO A POLICE FORCE OR OTHER AUTHORIZED BODY. THAT POLICE FORCE OR AUTHORIZED
BODY WILL THEN DISCLOSE THAT INFORMATION TO ME. IF I FURTHER CONSENT IN WRITING TO DISCLOSURE OF THAT INFORMATION TO THE PERSON OR
ORGANIZATION REFERRED TO ABOVE THAT REQUESTED THE VERIFICATION, THAT INFORMATION WILL BE DISCLOSED TO THAT PERSON OR
ORGANIZATION.
Applicant’s Signature Date | yyyy/mmm/dd
Personal information is collected on this form pursuant to the Municipal Freedom of Information and Protection of Privacy Act, s. 28(2), s.32(b) and the
Police Services Act, s.41 for the purpose of processing this record check. Questions concerning this collection can be directed to: Records Supervisor,
Hamilton Police Service, 155 King William Street, Hamilton, Ontario L8R 1A7 (905) 546-4767.
101312 DEC18