This is a Pan-Canadian Policy applicable to Volleyball Canada and the Provincial/Territorial Associations.
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Appendix C – Screening Renewal Form
NAME: __________________________________________________________________________________
First Middle Last
CURRENT PERMANENT ADDRESS:
____________________________________________________________________________________
Street City Province Postal
DATE OF BIRTH: _______________________ GENDER IDENTITY: ________________
Month/Day/Year
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 Volleyball
Canada or to a Provincial/Territorial Association. 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 Volleyball
Canada or my Provincial/Territorial Association. 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: _________________________
