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NOTE : Reference document CD 710-8
PERSONAL INFORMATION BANK
STATEMENT OF VOLUNTARY PARTICIPATION AND CONSENT FOR PRIVATE FAMILY VISITS
IMPORTANT
PLEASE READ THIS FORM CAREFULLY. Answer all questions and sign in the applicable spaces. You are also required to ensure that you have completed Visiting Application and Information form (Inmate) CSC/SCC 0653E and, if applicable, the Visiting Application - Child Safety Waiver (CSC/SCC 0653-01E) forms. The visiting Application and the Child Safety Waiver remain valid for a period of two years. If you need help to complete any of the forms, please contact the institution you wish to visit. Send the completed form(s) and photographs of all participants to the institution (refer to the Correctional Service of Canada site for the appropriate address of the institution
PRIVACY ACT STATEMENT
Personal information about you is collected under the authority of the Corrections and Conditional Release Act to review your suitability for private family visiting privileges at the CSC. This information is collected, with no obligation on your part, and held in the Visits and Correspondence Bank; however, your refusal to comply would result in the denial of visiting privileges. This information cannot be disclosed to other persons without your consent EXCEPT where disclosure would be justified pursuant to one of the paragraphs of subsection 8 (2) to the Privacy Act.
Completed by: Visitor
Family Name

Family NameGiven Name
Maiden Name (if Applicable)
Your Date of Birth
YYYY/MM/DD
Your Place of Birth
City / Town
Province
Your Present Address
Phone Number
Address

Street Address

Apt No

CityState / Province

Postal / Zip Code
Telephone number(s) where a CSC representative could contact you if necessary (you may be contacted for an interview)
Home
Alternative Phone Number
Work (Telephone Number)
Civil Status(e.g. single, common-law, married, divorced, widowed, etc.)
Occupation e.g. unemployed, student, employed – please provide employer name, etc
1. Are you currently an approved visitor for the inmate?

YesNo If No, please ensure that the Visiting Application and Information From (Inmate) (CSC/SC 0653E) form is also completed and submitted.
2. Have you visited this inmate at a federal institution before?

YesNo
If the answer is Yes, please provide the institution name, location, and most recent date of your visit.
Information may be accessible or protected as required under the provisions of the Access to Information Act and the Privacy Act.
DISTRIBUTION
Offender VC File Visitor Private Family Visit File (3280-3)
For the following questions, if you need more space to explain your situation, please feel free to attach a separate page.
3. What is the nature of the relationship between you and the inmate? Please include how long you have been in this relationship and indicate if you resided with the inmate prior to the inmate being incarcerated. (If applicable, please complete and submit Declaration of a Common-Law Union (CSC/SCC 0530E
4. Why do you wish to participate in Private Family Visits?
5. Are you familiar with the inmate’s criminal history, offence(s) for which the inmate is currently incarcerated, and what led to the inmate committing the offence(s)?

YesNo
Please explain:
6. Has the inmate ever been physically or psychologically abusive toward you?

YesNo
Please explain:
7. Do you have any concerns regarding violent behaviour from the inmate or is there any history of violent behaviour by the inmatethat you are aware of?

YesNo
Please explain:
8. Do you have any safety or other concerns regarding your participation in Private Family Visits?

YesNo
Please explain:
9. Do you have any children who will be participating in Private Family Visits?

YesNo
If Yes, please ensure that the Visiting Application - Child Safety Waiver No (CSC/SCC 0653-01E) form is also completed and submitted.
i.) Is the inmate the parent of the child/children participating in Private Family Visit?

YesNo
ii.) What is the nature of the relationship between your child / children and the inmate? (if more than one child, please specify for each child)
10. Specific goods required during Private Family Visits (e.g diapers, baby food, powdered milk, etc.):

YesNo
If Yes, please explain :
11. Do you have any special needs requiring accommodations? e.g. wheelchair, hearing impaired, etc

YesNo
If Yes, please explain :
12. Please provide a list of medications and dosage you are required to take during Private Family Visits.
Note: The visitor must ensure that all medication brought to the institution is in the original container, correspond to his/her name and has the prescribed dosage amount required for the duration of the Private Family Visit. Medication will be held at the principle entrance in a locked box and access will be arranged when it is required. Any excessive amounts of will be returned to the visitor upon exiting the institution.
13. Any other information you wish to share with us?

YesNo
If Yes, please explain
14. Are you aware of the rules, regulations and security procedures at the institution?

YesNo if No please visit our website (www.csc-scc.gc.ca) and/or contact the institution you wish to visit.
I,
Name of visitor (print)
request permission, voluntarily, to participate in Private Family Visits at
Name of institution
Institution. I understand, and agree to abide by all rules and regulations of Private Family Visits during my visit with
Name of inmate (print)
Recognizing the risks inherent in visiting within an Institution and in consideration for the risk to participate voluntarily in Private Family Visits, I do hereby for myself, my heirs, executors, administrators and assigns, remise, release and forever discharge His Majesty the King in right of Canada, the Correctional Service Canada and any of its employees from all manner of actions, causes of actions, claims or demands, of whatever kind or nature for damages, loss or injury, which I may hereafter have against them or any of them as a result of in any way arising out of or connected with my voluntary participation in Private Family Visits.
PROVISION OF INFORMATION TO THE CORRECTIONAL SERVICE OF CANADA
The Correctional Service of Canada has a responsibility under subsections 27(1) and (2) of the Corrections and Conditional Release Act to share the information with the offender, unless it meets one of the exceptions set out in subsection 27(3) of the Act, e.g., where there are reasonable grounds to believe that disclosure to the offender would jeopardize: (1) the safety of any person (2) the security of a penitentiary, or (3) the conduct of any lawful investigation Furthermore, even if one, or more, of the above is met, it may be necessary to provide at least a “gist” of that information to the offender as outlined in Annex C of Commissioner’s Directive 701 Information Sharing.
By signing this form, I certify that I,
Name of visitor (print)
am the individual signing this STATEMENT OF VOLUNTARY

PARTICIPATION AND CONSENT FOR PRIVATE FAMILY VISITS, I am not signing while under duress (e.g. being threatened or forced ), and affirming my wish to voluntarily participate in the Private Family Visit Program and that the information provided is true and correct to the best of my knowledge.
Visitor – Signature

Clear
Date (YYYY-MM-DD)

MonthDayYear
Date
Name of Witness (print)
Witness – Signature

Clear
Date (YYYY-MM-DD)

MonthDayYear
Date
To be completed if the visitor is under the age of majority in the province where the institution is located.

Age of majority: the age at which a person is considered to be an adult by a province or territory where the institution someone wishes to visit is located.
I,
Name of visitor (print)
Being the

ParentGuardian of
Name of child (print)
request permission for him/her to participate in Private Family Visits. I assume the responsibility of ensuring that he/she abides by all rules and regulations of
Private Family Visits during his/her visit with
Name of inmate (print)
recognizing the risks inherent in visiting an institution and in consideration for the right for
Name of child (print)
to participate in Private Family Visits, I do hereby agree to indemnify and save harmless His Majesty the King in right of Canada, the Correctional Service Canada or any of its employees in respect of any claim, loss, damage or expense relating to any injury alleged to be caused as a result of
Name of child (print)
Name of child (print)
voluntary participation in Private Family Visits
Name of Parent / Guardian (print)
Signature

Clear
Date (YYYY-MM-DD)

MonthDayYear
Date
Name of Parent / Guardian (print)
Signature

Clear
Date (YYYY-MM-DD)

MonthDayYear
Date
Completed by: Correctional Service of Canada official

CSC/SCC 0531e (R-2016-08) (Word Version & PDF) Page 5 of 5
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PROTECTED

B ONCE COMPLETED

PERSONAL INFORMATION BANK

STATEMENT OF VOLUNTARY PARTICIPATION AND CONSENT FOR PRIVATE FAMILY VISITS

IMPORTANT

PRIVACY ACT STATEMENT

Completed by: Visitor

Your Date of Birth

Your Place of Birth

Your Present Address

DISTRIBUTION

PROVISION OF INFORMATION TO THE CORRECTIONAL SERVICE OF CANADA