Safe Sport Disclosure Form | Alberta Whitewater Association

Contact

First Name

Last Name

Nickname

Birth Date

Street Address

City

Postal Code

Club

Existing Contact

Role

Safe Sport Self Disclosure Form Questions

Note: Failure to disclose truthful information below may be considered an intentional omission and the loss of volunteer responsibilities or other privileges

1. Have you been convicted of a crime?

If so, please complete the following information for each conviction.

Yes

Name or Type of Offense

Name and Jurisdiction of Court/Tribunal:

Year Convicted:

Penalty or Punishment Imposed:

Further Explanation:

2. Have you ever been disciplined or sanctioned by a sport governing body or by an independent body

Yes

(e.g., private tribunal, government agency, etc.) or dismissed from a coaching or volunteer position? If so, please complete the following information for each disciplinary action or sanction.

Name of disciplining or sanctioning body:

Date of discipline, sanction or dismissal:

Reasons for discipline, sanction or dismissal:

Punishment or Penalty Imposed:

Further Explanation

3. Are criminal charges or any other sanctions, including those from a sport body, private tribunal or government agency, currently pending or threatened against you?

Yes

If so, please complete the following information for each pending charge or sanction.

Name or Type of Offense

Name and Jurisdiction of Court/Tribunal:

Name of disciplining or sanctioning body:

Further Explanation:

PRIVACY STATEMENT By completing and submitting this Screening Disclosure Form, I consent and authorize the Alberta Whitewater Association to collect, use and disclose my personal information, including all information provided on the Screening Disclosure Form as well as my Enhanced Police Information Check and/or Vulnerable Sector Check (when permitted by law) for the purposes of screening, implementation of the Screening Policy, administering membership services, and communicating with National Sport Organizations, Provincial Sport Organizations, Divisions, Discipline-Specific Provincial Sport Organizations, Clubs, and other organizations involved in the governance of sport. Alberta Whitewater Association and its Members do not distribute personal information for commercial purposes.

CERTIFICATION I hereby certify that the information contained in this Screening Disclosure Form is accurate, correct, truthful and complete. I further certify that I will immediately inform Alberta Whitewater Association or the Member (as applicable) of any changes in circumstances that would alter my original responses to this Screening Disclosure Form. Failure to do so may result in the withdrawal of volunteer responsibilities or other privileges and/or disciplinary action.

Date

Signature

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Safe Sport Verification

Safe Sport Screening 2024

Safe Sport Training

Self Disclosure Form

Police Check

Vulnerable Sector Check