Baseball Ontario Screening Disclosure Form (Orangeville & Headwaters Minor Baseball)

Baseball Ontario Screening Disclosure Form
Baseball Ontario's Appendix 1 - Screening Disclosure Form and Privacy Statement

Name

Current Permanent Address

Background

Question 1

Have you ever been convicted of a crime for which a pardon has not been granted?

Question 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?

Question 3

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

Question 4

Have you ever been the subject of a decision of a court or tribunal that might reflect adversely on the profession of coaching, the sport of baseball, or any other sport?

Question 5

Have you ever been dismissed from a position due to allegations of ethical or moral misconduct?

Question 6

Have you ever been disciplined or sanctioned by an international sport tribunal, by a National sport governing body outside Canada, by a National Sport Organization within Canada, or by any other sport organization?

Addition(s)

For more than one conviction please attach additional page(s) as necessary.

Certification

I herby 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.

Privacy Statement

By completing and submitting this Screening Disclosure Form, you consent and authorize the Organization to collect, use and disclose your personal information, including all information provided on the Screening Disclosure Form, Police Record Check and/or Vulnerable Sector Check for the purposes of screening, implementation of the Organization's Screening Policy, administering membership services and communicating with other National Sport Organizations, Provincial Sport Organizations, Sport Organizations, and other organizations involved in the governance of the sport of baseball. The Organization does not distribute personal information for commercial purposes.