2024 Screening Disclosure Form and Privacy Statement (Lucan-Ilderton Baseball)

PERSONAL INFORMATION

Last Name^*

Required

First Name^*

Required

Middle Name^*

Required

Other Names You Have Used

Street Address^*

Required

Suite Number

City^*

Required

Postal Code^*

Required

Birth Day^*

Required

Birth Month^*

Required

Birth Year^*

Required

Phone Number^*

Required

Example: ###-###-####

Email Address:^*

Required

NCCP #^*

Required

Select Age Group or Role^*

5U Blastball
7U Junior Rookie
9U Baseball
11U Baseball
13U Baseball
15U Baseball
18U Baseball
U11 Girls Softball
U13 Girls Softball
U15 Girls Softball
U17 Girls Softball
U19 Girls Softball
Board member

Required

DISCLOSURE INFORMATION

NOTE: 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 THE ORGANIZATION'S SCREENING POLICY

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

YESNO

Required

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

Required

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

Required

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

Required

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

Required

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

Required

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

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.^*

YESNO

Required

DATE; MM/DD/YYYY^*

Required

I agree to the terms and conditions stated above^*

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2024 Screening Disclosure Form and Privacy Statement (Lucan-Ilderton Baseball)

PERSONAL INFORMATION

DISCLOSURE INFORMATION

CERTIFICATION

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