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 ONE box that applies to you:*

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

All reportable matters as described above were discussed with Agency Staff and/or the Chief Executive Officer 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*

Name of Witness*

Full Name

Date*

Consent*

By checking this box, signing and/or submitting this form, you are consenting to the collection and use of your personal information by Big Brothers Big Sisters of Waterloo Region and Big Brother Big Sisters of Canada (BBBSC). We will use your personal information, and personal information will only be disclosed to authorized personnel when deemed necessary. You may withdraw consent at any time; however, withdrawal may affect your eligibility as a volunteer The personal information you provide may be stored in provinces or countries other than your place of residence and maintained for as long as required to fulfill any business/legal requirements. In all circumstances, your personal information will be managed in accordance with the privacy policies of Big Brothers Big Sisters of Waterloo Region and BBBSC.

Name

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

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