Ringette Manitoba - Screening Disclosure Forn

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 *

Position (Coach, Instructor etc.) *

What position are you holding? *

Option 1 Option 2

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. Have you ever been convicted of a crime for which a pardon has not been granted, including possession or trafficking of an illegal substance? If yes, please describe below for each conviction: *

If yes, please explain.

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 explain

Yes No

Name or Type of Offense:

Name and Jurisdiction of Court/Tribunal:

Further Explaination

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

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

Further Explanation

4. Have you ever been dismissed from a position due to allegations of ethical or moral misconduct? If yes, please explain *

If yes, please explain

Yes No

Name of applicable organization

Date of Dismissal

Reason for Dismissal

5. Have you ever been disciplined or sanctioned by an independent body (sport body, private tribunal, government agency, etc.) for which a pardon has not been granted? *

If yes, please explain

Yes No

Name or Type of Offense

Name and Independent Body

Year Convicted

Further explaination

Penalty or Punishment Imposed

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

Date *

PRIVACY STATEMENT

By completing and submitting this Screening Disclosure Form, you consent and authorize Ringette Manitoba to collect, use and disclose your personal information, including all information provided on the Screening Disclosure Form for the purposes of screening, and communicating with other organizations involved in the governance of the sport. Ringette Manitoba does not distribute personal information for commercial purposes.