Screening Disclosure Form and Privacy Statement (Lucan-Ilderton Baseball)

1. HAVE YOU EVER BEEN CONVICTED OF A CRIME FOR WHICH A PARDON HAS NOT BEEN GRANTED?^*

YESNO

If yes, please describe below for each conviction. Name or Type of Offense, Name and Jurisdiction of Court/Tribunal, Year Convicted, Penalty or Punishment Impose, and any 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?^*

YESNO

If yes, please explain for each pending charge -- Name or type of Offence, Name and Jurisdiction of Court/Tribunal and any further explanation if necessary

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 OF BASEBALL OR ANY OTHER SPORT?^*

YESNO

If yes, please describe each finding, judgment or ruling below. Civil Court Finding, Out of Court Settlement, Type of Finding, Year of Offence or Settlement, Penalty or Punishment Imposed. And any further explanation if necessary.

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?^*

YESNO

If yes, please describe below -- type of offence, year of decision, penalty or punishment imposed, and any further explanation if necessary

5. HAVE YOU EVER BEEN DISMISSED FROM A POSITION DUE TO ALLEGATIONS OF ETHICAL OR MORAL MISCONDUCT?^*

YESNO

If yes, please describe below --- name of applicable organization, date of dismissal, reason for dismissal

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?^*

YESNO

If yes, please describe below -- name of applicable organization, date of discipline or sanction, reason for discipline or sanction,