Offence Declaration Form

"*" indicates required fields

I DECLARE, since the last Criminal Records Check provided to Big Brothers Big Sisters of Waterloo Region or since the last Offence Declaration Form submitted to Big Brothers Big Sisters of Waterloo Region, that:

Please check all boxes that apply:

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).

I have no pardons related to sexually based offences up to and including the date of this declaration under the Criminal Records Act (Canada).

I have no charges pending under the Criminal Code of Canada up to and including the date of this declaration.

I have not been the subject of any criminal investigation or allegation, any child welfare investigation or allegation, nor have I had any charges brought against me, even if the charges are pending.

My driver’s license has not been suspended, restricted or revoked for any reason.

Please check the appropriate box:*

There have been no occurrences as described above since my last Criminal Record Check or OffenceDeclaration Form.

All reportable matters as described above were discussed with Agency Staff and/or the Chief ExecutiveOfficer at the time of the occurrence(s).

Valid Declaration*

I hereby attest that the information disclosed herein is true, complete and accurate to the best of my knowledge and belief. I understand that failure to complete an accurate and truthful Offence Declaration will affect my involvement with Big Brothers Big Sisters of Waterloo Region.

Name of Volunteer*

Full Name

Email of Volunteer*

Name of Witness*

Full Name

Date*

Consent*

By signing this form, I consent to the collection and use of my personal information disclosed herein by authorized personnel at Big Brothers Big Sisters of Waterloo Region and Big Brother Big Sisters of Canada (BBBSC) for the purpose of assessing my eligibility as a volunteer, assessing my continued involvement with the agency, etc. I understand that I may withdraw consent at any time; however, withdrawal may affect my involvement with Big Brothers Big Sisters of Waterloo Region.

Comments

This field is for validation purposes and should be left unchanged.

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