DMBA Screening Disclosure Form and Privacy Statement (Dorchester Baseball)

Print DMBA Screening Disclosure Form and Privacy Statement
  1. Street, City, Province, Postal Code
  2. Month/Day/Year
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:
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.
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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.
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