Fillable Appendix B Screening Disclosure Form (Volleyball Alberta)

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Appendix B Screening Disclosure Form (Volleyball Alberta)

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This is a Pan-Canadian Policy applicable to Volleyball Canada and the Provincial/Territorial Associations.
www.volleyballalberta.ca
Page 1 | 2
Appendix B – Screening Disclosure Form
N
AME: __________________________________________________________________________________
First Middle Last
O
THER NAMES YOU HAVE USED: ____________________________________________
C
URRENT PERMANENT ADDRESS:
____
_____________________________________________________________________________
Street City Province Postal
D
ATE OF BIRTH: ________________________________ GENDER IDENTITY: ________________
Month/Day/Year
C
LUB (if applicable): ____________________________ EMAIL: _________________________
N
ote: 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
a
dditional pages as necessary.
N
ame or type of offense: ________________________________________________________
Name and Jurisdiction of Court/Tribunal: ___________________________________________
Yea
r convicted: _______________________________________________________________
P
enalty or punishment imposed: ________________________________________________
F
urther 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 page(s) as necessary.
N
ame of disciplining or sanctioning body: _________________________________________________
D
ate of discipline, sanction or dismissal: __________________________________________________
R
easons for discipline, sanction or dismissal: ______________________________________________
Penalty or punishment imposed: ________________________________________________________
F
urther explanation: _________________________________________________________________
This is a Pan-Canadian Policy applicable to Volleyball Canada and the Provincial/Territorial Associations.
www.volleyballalberta.ca
Page 2 | 2
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 Volleyball Canada and/or a
Provincial/Territorial Association 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 Sport Organizations,
and other organizations involved in the governance of sport. Volleyball Canada and the Provincial/Territorial
Associations 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 Volleyball Canada or a Provincial/Territorial Association (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: _________________________
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Appendix B Screening Disclosure Form (Volleyball Alberta)

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Completed 7 February 2021

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