Softball Ontario - Screening Disclosure Form

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Full Name: (First, Middle, Last) *

Position: *

Other Names You Have Used:

Current Permanent Address:

Street: *

City: *

Province: *

Postal: *

Date of Birth: (MM/DD/YY) *

Gender: *

Female

Male

Other:

Phone: *

Email: *

Note: Failure to disclose a conviction/sanction for which a pardon has not been granted may be considered an intentional omission and subject to failure of screening requirements as required by Softball Ontario.

1. I DECLARE, since the last Criminal Background Check collected by Softball Ontario, or since the last Screening Disclosure Form submitted by me to Softball Ontario, that: *

I have no convictions under the Criminal Code of Canada up to and including the date of this declaration for which a pardon has not been issued or granted under the Criminal Records Act (Canada).

I have the following convictions for offences under the Criminal Code of Canada for which a pardon under the Criminal Records Act (Canada) has not been issued or granted: (List under "other" below)

Other:

Required

Have you ever been convicted for a crime for which a pardon has not been granted, including possession or trafficking of an illegal substance? *

Yes

If you answered yes to the above question, 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:

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

If you answered yes to the above question, please describe below for each pending charge:

Name or Type of Offense:

Name and Jurisdiction of Court/Tribunal:

Year Convicted:

Penalty or Punishment Imposed:

Further Explanation:

Has any civil court made a finding, judgement or ruling against you, relevant to the profession of coaching/officiating or the sport of softball? *

Yes

If you answered yes to the above question, please describe each finding, judgement or ruling below:

Type of Offense or Finding:

Year of Offense:

Penalty or Punishment Imposed:

Further Explanation:

Have you ever been dismissed from a coaching /officiating position due to allegations of ethical or moral misconduct? *

Yes

If you answered yes to the above question, please describe below:

Name of Applicable Organization:

Date of Dismissal:

Reason for Dismissal:

Have you ever been disciplined or sanctioned by a sport governing body outside Canada or by any other body within Canada that governs the sport of softball or the coaching/officiating profession? *

Yes

If you answered yes to the above question, please describe below:

Name of Applicable Organization:

Date of Discipline or Sanction:

Reason for Discipline or Sanction:

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 Softball Ontario of any changes in circumstances that would alter my original responses to this Screening Disclosure Form. Failure to do so may result in termination.

Acknowledgement by checking the "I Agree" box, the Parties are consenting to the use of their electronic agreement in lieu of an original signature on paper. Electronic Consent. *

I Agree

Required

Full Name: *

Date: *

YYYY

Submit

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