Gymnastics Saskatchewan - GymSask Screening Disclosure Form and Criminal Record Check

Level 1 & 2 members are required to fill out this screening disclosure form, including a criminal record check, every three years.
Level 3 members are required to fill out this screening disclosure form annually.
More information can be found in our Safe Sport policies at https://www.gymsask.com/policydocs.

Contact Information

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(You will receive a copy of this form via email for your records.)

First name *

Last name *

Club (if applicable)

Email *

Date of birth *

Address *

City *

Country *

State/Province *

Region *

Zip/Postal code *

Have you been convicted of a crime? *

Yes No x Clear

Name or Type of Offense: *

Name or Type of Offense:

Names and Jurisdiction of Court/Tribunal: *

Names and Jurisdiction of Court/Tribunal:

Year Convicted: *

Year Convicted:

Penalty or Punishment Imposed: *

Penalty or Punishment Imposed:

Further Explanation: *

Further Explanation:

Have you ever been disciplined or sanctioned by a sport governing body, club, or by an independent body (e.g., private tribunal, government agency, etc.)? *

Yes No x Clear

Name of disciplining or sanctioning body: *

Name of disciplining or sanctioning body:

Date of discipline, sanction or dismissal: *

Date of discipline, sanction or dismissal:

Reasons for discipline, sanction or dismissal: *

Reasons for discipline, sanction or dismissal:

Penalty or Punishment Imposed: *

Penalty or Punishment Imposed:

Further Explanation: *

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 No x Clear

Name or Type of Offense: *

Name or Type of Offense:

Name and Jurisdiction of Court/Tribunal: *

Name and Jurisdiction of Court/Tribunal:

Name of disciplining or sanctioning body: *

Name of disciplining or sanctioning body:

Furthere Explanation: *

Furthere Explanation:

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