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RMMSA Ridge Meadows Minor Softball Association

And 

SBBC Softball BC

Screening Disclosure Form

Please fill out this form if you are a Coach or Manager

By checking "I Agree" below, I understand and agree that 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 RMMSA and Softball BC.

 

I Agree

First Volunteer Name

First Name*

Middle Name

Last Name*

Phone*
First Volunteer Date of Birth*
First Volunteer Information

Other Names You Have Used

Position

Current Permanent Address


Street *

City *

Province *

Postal Code *
First Volunteer Signature*
Second Volunteer Name

First Name*

Middle Name

Last Name*
Second Volunteer Date of Birth*
Second Volunteer Information

Other Names You Have Used

Position

Current Permanent Address


Street *

City *

Province *

Postal Code *
Third Volunteer Name

First Name*

Middle Name

Last Name*
Third Volunteer Date of Birth*
Third Volunteer Information

Other Names You Have Used

Position

Current Permanent Address


Street *

City *

Province *

Postal Code *
Fourth Volunteer Name

First Name*

Middle Name

Last Name*
Fourth Volunteer Date of Birth*
Fourth Volunteer Information

Other Names You Have Used

Position

Current Permanent Address


Street *

City *

Province *

Postal Code *
Fifth Volunteer Name

First Name*

Middle Name

Last Name*
Fifth Volunteer Date of Birth*
Fifth Volunteer Information

Other Names You Have Used

Position

Current Permanent Address


Street *

City *

Province *

Postal Code *
Sixth Volunteer Name

First Name*

Middle Name

Last Name*
Sixth Volunteer Date of Birth*
Sixth Volunteer Information

Other Names You Have Used

Position

Current Permanent Address


Street *

City *

Province *

Postal Code *
Seventh Volunteer Name

First Name*

Middle Name

Last Name*
Seventh Volunteer Date of Birth*
Seventh Volunteer Information

Other Names You Have Used

Position

Current Permanent Address


Street *

City *

Province *

Postal Code *
Eighth Volunteer Name

First Name*

Middle Name

Last Name*
Eighth Volunteer Date of Birth*
Eighth Volunteer Information

Other Names You Have Used

Position

Current Permanent Address


Street *

City *

Province *

Postal Code *
Ninth Volunteer Name

First Name*

Middle Name

Last Name*
Ninth Volunteer Date of Birth*
Ninth Volunteer Information

Other Names You Have Used

Position

Current Permanent Address


Street *

City *

Province *

Postal Code *
Tenth Volunteer Name

First Name*

Middle Name

Last Name*
Tenth Volunteer Date of Birth*
Tenth Volunteer Information

Other Names You Have Used

Position

Current Permanent Address


Street *

City *

Province *

Postal Code *
Parent or Guardian's Email Address

Email*

Confirm Email*
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Section 1
I DECLARE, since the last Criminal Background Check collected by RMMSA or Softball BC since the last Screening Disclosure Form submitted by me to RMMSA or Softball BC, 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). Go to next section.
I have the following convictions under the Criminal Code of Canada for which a pardon under the Criminal Records Act (Canada) has not been issued or granted:

Please List Convictions
Section 2
Have you ever been convicted of a crime for which a pardon has not been granted, including possession or trafficking of an illegal substance?*
No (Go to next section)
Yes (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
Section 3
Are criminal charges or any other sanctions, including those from a sport body, private tribunal or government agency, currently pending or threatened against you?*
No (Go to next section)
Yes (Please describe below for each pending charge)

Name or Type of Offense

Name and Jurisdiction of Court/Tribuna

Further Explanation
Section 4
Has any civil court made a finding, judgment or ruling against you, relevant to the profession of coaching or the sport of softball?*
No (Go to next section)
Yes (Please describe each finding, judgment or ruling below)

Type of Offense or Finding

Year of Offense

Penalty or Punishment Imposed

Further Explanation
Section 5
Have you ever been dismissed from a coaching position due to allegations of ethical or moral misconduct?*
No (Go to next section)
Yes Please describe below

Name of applicable Organization

Date of Dismissal:

Reason for Dismissal
Section 6
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 profession?*
No (Go to next section)
Yes (Please describe below)

Name of applicable Organization

Date of Discipline or Sanction

Reason for Discipline or Sanction
Certification

I hereby certify, by checking the "I Agree" box below and by providing my electronic signature that the information contained in this application is accurate, correct, truthful and complete.

I further certify that I will immediately inform RMMSA or Softball BC of any changes in circumstances that would alter my original responses to this Screening Disclosure Form. I understand Failure to do so may result in termination or immediate dismissal from my volunteer position.

Certification *
I Agree
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Other Names You Have Used

Position

Current Permanent Address


Street *

City *

Province *

Postal Code *
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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