Offence Declaration Form - Big Brothers Big Sisters of Waterloo Region

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:

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 or restricted 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 lead to a review of my continued service with Big Brothers Big Sisters of Waterloo Region.

Name of Volunteer*

Full Name

Email of Volunteer*

Name of Witness*

Full Name

Date*

Consent*

I have read, understand and completed the Offence Declaration Form. By clicking YES I hereby confirm that the information provided is accurate, correct and complete to the best of my knowledge. I authorize Big Brothers Big Sisters of Waterloo Region to use the information I provided within their agency.