Screening Disclosure

SCREENING DISCLOSURE

Full Legal Name

Birthday

Street Address

Street Address Line 2

City

Province

Postal Code

Have you been convicted of a crime? If you answer YES, additional screening questions will be required.

YES

Have you ever been disciplined or sanctioned by a sport governing body or by an independent body (e.g., private tribunal, government agency, etc.) or dismissed from a coaching or volunteer position? If you answer YES, additional screening questions will be required.

YES

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 you answer YES, additional screening questions will be required.

YES

By completing and submitting this Screening Disclosure Form, I consent and authorize Karate New Brunswick to collect, use and disclose my personal information, including all information provided on the Screening Disclosure Form as well as my Enhanced Police Information Check and/or Vulnerable Sector Check (when permitted by law) for the purposes of screening, implementation of the Screening Policy, administering membership services, and communicating with National Sport Organizations, Provincial/Territorial Sport Organizations, Clubs, and other organizations involved in the governance of sport. Karate New Brunswick does not distribute personal information for commercial purposes.

I hereby certify that the information contained in this Screening Disclosure Form is accurate, correct, truthful and complete. I further certify that I will immediately inform Karate New Brunswick (as applicable) of any changes in circumstances that would alter my original responses to this Screening Disclosure Form. Failure to do so may result in the withdrawal of volunteer responsibilities or other privileges and/or disciplinary action.