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Screening Disclosure Form
NAME: __________________________________________________________________________________________________________________
First Middle Last
OTHER NAMES YOU HAVE USED: ___________________________________________________________
CURRENT PERMANENT ADDRESS:
__________________________________________________________________________________________________________________________
Street City Province Postal
DATE OF BIRTH: ______________________________________ GENDER IDENTITY: ______________________
Month/Day/Year
CLUB: ________________________________________________ EMAIL: _________________________
Note: Failure to disclose a conviction/sanction may be considered an intentional omission and subject to
failure of screening requirements as required by Volleyball Alberta’s
Screening Policy
.
1. Have you ever been convicted of a crime?
Yes ________ No________ If yes, please describe below for each conviction:
Name or Type of Offense: _____________________________________________________________________________________
Name and Jurisdiction of Court/Tribunal: _____________________________________________________________________
Year Convicted: ________________________________________________________________________________________________
Penalty or Punishment Imposed: ______________________________________________________________________________
Further Explanation: ___________________________________________________________________________________________
_________________________________________________________________________________________________________________
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2. Are criminal charges or any other sanctions, including those from a sport body, private tribunal or
government agency, currently pending or threatened against you?
Yes_______ No_______ If yes, please explain for each pending charge:
Name or Type of Offense: _____________________________________________________________________________________
Name and Jurisdiction of Court/Tribunal: _____________________________________________________________________
Further Explanation: ___________________________________________________________________________________________
_________________________________________________________________________________________________________________
3. Have you ever been subject to a lawsuit relevant to coaching or to sports in general?
Yes ________ No________ If yes, please describe each finding, judgment or ruling below:
Court Finding: Out of Court Settlement:
Type of Offense or Finding: ___________________________________________________________________________________
Year of Offense or Settlement: ________________________________________________________________________________
Further Explanation: ___________________________________________________________________________________________
_________________________________________________________________________________________________________________
4. Have you ever been subject to a settlement agreement, plea bargain, charges stayed, etc. relevant to
coaching or to sports in general?
Yes ________ No________ If yes, please describe below:
Court Finding: Out of Court Settlement:
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Type of Offense or Finding: ___________________________________________________________________________________
Year of Offense or Settlement: ________________________________________________________________________________
Further Explanation: ___________________________________________________________________________________________
_________________________________________________________________________________________________________________
5. Have you ever been dismissed from a coaching position?
Yes ________ No________ If yes, please describe below:
Name of applicable Organization: _____________________________________________________________________________
Date of Dismissal: ______________________________________________________________________________________________
Reason for Dismissal: __________________________________________________________________________________________
_________________________________________________________________________________________________________________
6. Have you ever been disciplined or sanctioned by an international sport body, by a National sport
governing body outside Canada, or by any other body within Canada that governs any sport?
Yes ________ No________ If yes, please describe below and provide a copy of the decision:
Name of applicable Organization: _____________________________________________________________________________
Date of Discipline or Sanction: ________________________________________________________________________________
Reason for Discipline or Sanction: _____________________________________________________________________________
_________________________________________________________________________________________________________________
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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.
Certification
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: ______________________
PRIVACY STATEMENT:
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.
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