Ringette Manitoba - Screening Disclosure Form

Personal Information

You will receive a confirmation by email.

First name *

Last name *

Email *

Mobile

Gender *

Date of birth *

Address *

City *

Country *

State/Province *

Zip/Postal code *

Middle Name

Other Names Used

Maiden Name

Association *

Position *

Coach Instructor Manager Official Trainer Volunteer Other

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.

1. Do you have a criminal record? *

If yes, please complete fields below.

Yes No

Name or Type of Offence:

Name and Jurisdiction of Court/Tribunal:

Year Convicted

Penalty or Punishment Imposed:

Further Explanation:

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? *

If yes, please complete fields below.

Yes No

Name or Type of Offense:

Name and Jurisdiction of Court/Tribunal:

Further Explanation

3. Has any civil court made a finding, judgment or ruling against you, or have you entered into an out of court settlement relevant to the profession of coaching, the sport or any other sport? *

If yes, please explain

Yes No

Civil Court Finding

Type of Offense of Finding

Out of Court Settlement

Year of Offense or Settlement

Penalty or Punishment Imposed

Further Explanation

4. Have you ever been disciplined or sanctioned by an independent body (sport body, private tribunal, government agency, etc.) or dismissed from a coaching or volunteer position? *

If yes, please complete fields below

Yes No

Name or Type of Offense

Name and Independent Body

Year Convicted

Penalty or Punishment Imposed

Further Explanation

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 the Organization 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.

Electronic signature*

Please sign your name inside the box. A typed signature will be considered official and equivalent to a signature.

Date *

PRIVACY STATEMENT

By completing and submitting this Screening Disclosure Form, I consent and authorize the Organization to collect, use and disclose my personal information, including all information provided on the Screening Disclosure Form as well as my Criminal Record and Judicial Matters Check (when permitted by law) for the purposes of screening, implementation of the Organization’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 sport. The Organization does not distribute personal information for commercial purposes.