7. Have you ever been disciplined or sanctioned by an independent body (sport body, private tribunal,
government agency, etc.)?
Yes ________ No________ If yes, please describe below:
Name or Type of Offense: _____________________________________________________________________________________
Name and Independent Body: ________________________________________________________________________________
Year Convicted: ________________________________________________________________________________________________
Penalty or Punishment Imposed: ______________________________________________________________________________
Further Explanation: ___________________________________________________________________________________________
For more than one conviction please attach additional page(s) as necessary.
I hereby certify that the information contained in this application is accurate, correct, truthful and complete.
I further certify that I will immediately inform Volleyball Alberta of any changes in circumstances that would
alter my original responses to this Screening Disclosure Form. Failure to do so may result in termination of
membership and/or further discipline.
Signature: ____________________________________________ Date: ______________________
By completing and submitting this Screening Disclosure Form, you consent and
authorize Volleyball Alberta to collect, use and disclose your personal information, including all
information provided on the Screening Disclosure Form, E-PIC, and/or Vulnerable Sector Check for the
purposes of screening, implementation of Volleyball Alberta’s Screening Policy, administering
membership services and communicating with National Sport Organizations, Provincial Sport
Organizations, Sport Clubs, and other organizations involved in the governance of the sport. Volleyball
Alberta does not distribute personal information for commercial purposes.
click to sign
click to edit