Offence Declaration Form

Annual Offence Declaration form

Name

First Last

Date

I DECLARE, since the last Criminal Records Check provided to Big Brothers Big Sisters of Dufferin and District, or since the last Annual Offence Declaration Form submitted to Big Brothers Big Sisters of Dufferin and District, 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 the appropriate line

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

All reportable matters as described above were discussed with Agency Staff and/or the Executive Director at the time of the occurrence(s).

Signature

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 Dufferin and District and Big Brother Big Sisters of Canada (BBBSC). We will use your personal information to ensure your adherence with Big Brothers Big Sisters child safety policies. Your personal information will only be disclosed to authorized personnel deemed necessary to ensure child safety policies are being met. 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 Dufferin and District and BBBSC.

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