Umpire Screening Application and Disclosure Form

RCA Umpire Screening: Application and Disclosure Form

Individuals who are active Rowing Canada Aviron Licensed Umpires must complete this Application and Screening Disclosure Form as well as an EPIC (Enhanced Police Information Check-similar to a Criminal Record Check). Upon completion of this form you will be directed to Sterling Backchecks' website where you can complete an EPIC at no charge. Once your screening forms are submitted you will receive a confirmation email to the email address you have provided. If the individual is applying for a new position within Rowing Canada Aviron, a new Application and Screening Disclosure Form may be required. All * fields are required.
Name*

First NameMiddle NameLast Name
Other names you have used:
E-mail (your screening results will be sent here)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Gender Identity*
Phone Number*

Area CodePhone Number
By signing the document below, I agree to be subject to and adhere to the policies and procedures of Rowing Canada Aviron, including but not limited to the Code of Conduct and Ethics, Conflict of Interest Policy, Privacy Policy and Screening Policy. Policies are located at the following link: https://rowingcanada.org/uploads/2021/04/RCA-Safe-Sport-Policy-Manual_FINAL.pdf

I recognise that I must pass certain screening requirements as outlined in the Screening Policy, and that the Screening Committee will determine my eligibility to volunteer in the position.
Todays Date*

MonthDayYear
Date
Signature*

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Screening Disclosure

Note: Intentional omission of truthful information below may result in the loss of responsibilities or other privileges.
Have you ever been convicted of a crime for which you have not received a pardon? *
Name of Offense:
Name of Court/Tribunal:
Year convicted:
Penalty imposed:
Further explanation (optional)
If you have been convicted of more than one crime that you have not received a pardon for, please provide additional information here for each conviction.
Have you ever been disciplined or sanctioned by a sport governing body or by an independent body (eg, private tribunal, government agency, etc.) or dismissed from a coaching or volunteer position? If yes to any of the questions above, 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:
Penalty
Further Explanation (optional)
If you have more than one disciplinary action or sanction, please provide information for each one here:
Are any criminal charges or other sanctions, including those from a sport body, private tribunal or government agency, currently pending against you? *
Name of Offense:
Name of Court/Tribunal:
Name of disciplining or sanctioning body:
Further Explanation (optional)
If you have more than one pending charge or sanction please provide information for each one here:
Provide at least one character reference related to the position. Please include, first and last name, email and phone number:*
IMPORTANT TO COMPLETE THE SCREENING PROCESS

Enhanced Police Information Check

To complete the screening process, an Enhanced Police Information Check (EPIC-similar to a Criminal Record Check) is required. To streamline this process for Umpires, Rowing Canada Aviron has partnered with Sterling Backcheck to complete your EPIC online at no charge to you. RCA has an account with Sterling Backcheck and the cost of this will be billed automatically to RCA, not you, the Umpire. Once you have submitted this form, a Thank You page will pop up with the link to Sterling Backcheck. You will be asked to create an online account with Sterling BackCheck (it will say "register here") and once complete you will be directed to the EPIC process. Please do this right after you have submitted to avoid any delays. Thank you very much.
Privacy Statement

By completing and submitting this Application and Screening Disclosure Form, I consent and authorize Rowing Canada Aviron 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 or Vulnerable Sector Check (when permitted by law) for the purposes of screening, implementation of the Screening Policy, administering membership services. To the extent necessary, the status of my screening application may be shared with National Sport Organizations (for example, if I belong to more than one sport), Provincial Rowing Associations (so they can fulfil their responsibilities under the Safe Sport Policy), Clubs and other organizations involved in the governance of sport. Rowing Canada Aviron 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.*

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RCA Umpire Screening: Application and Disclosure Form

Screening Disclosure

Privacy Statement