DMBA Screening Disclosure Form and Privacy Statement (Dorchester Baseball)

FIRST NAME^*

Required

MIDDLE NAME

LAST NAME^*

Required

OTHER NAMES YOU HAVE USED

CURRENT PERMANENT ADDRESS^*

Required

Street, City, Province, Postal Code

DATE OF BIRTH^*

Required

Month/Day/Year

GENDER

EMAIL^*

Required

Example: [email protected]

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 Offence

Name and Jurisdiction of Court/Tribunal

Year Convicted

Penalty or Punishment Imposed

Further Explanation

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

Further Explanation

Has any civil court made a finding, judgement 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, judgement or ruling below:

Civil Court Finding

YesNo

Out of Court Settlement

YesNo

Type of Finding

Year of Offence or Settlement

Penalty or Punishment Imposed

Further Explanation

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

Further Explanation

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

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 hereby 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 my membership and/or further discipline.

Digital Signature^*

Required

Type full name (first and last)

Date^*

Required

Today's date

PRIVACY STATEMENT

By completing and submitting this Screening Disclosure Form, you consent and authorize the Organization to collect, use and disclose your personal information, including all information provided on the Screening Disclosure Form, Police Record Check and/or Vulnerable Sector Check for the purposes of screening, implementation of the Organization’s Screening Policy, administering membership services and communicating with other National Sport Organizations, Provincial Sport Organizations, Sport Organizations, and other organizations involved in the governance of the sport of baseball. The Organization does not distribute personal information for commercial purposes.

I have read and understood this statement^*

YesNo

Required

DMBA Screening Disclosure Form and Privacy Statement (Dorchester Baseball)

If yes, please describe below for each conviction:

If yes, please explain for each pending charge:

If yes, please describe each finding, judgement or ruling below:

If yes, please describe below:

If yes, please describe below:

If yes, please describe below:

Certification

PRIVACY STATEMENT

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