RCA Screening Renewal Form

RCA Umpire Screening Renewal Form
As per Rowing Canada Aviron's Safe Sport Policy, individuals who are employees, contractors or volunteers of Rowing Canada Aviron must complete a screening process every three years and a Screening Renewal Form annually.

Thank you for your commitment of time and expertise to Rowing Canada Aviron as volunteers. Thank you also for taking the few minutes to fill out this renewal form. As leaders in our sport this demonstrates our deep commitment to Safe Sport.
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 certify that there have been no changes to my criminal record check since I last submitted an Enhanced Police Information Check and/or Criminal Record Check and/or Vulnerable Sector Check and Screening Disclosure and Application form and my drivers abstract to Rowing Canada Aviron. I further certify that there are no outstanding charges and warrants, judicial orders, peace bonds, probation or prohibition orders, or applicable non-conviction information, and there have been no absolute and conditional discharges.

I agree that any Enhanced Police Information Check and/or Criminal Record Check and/or Vulnerable Sector Check and Screening Disclosure and Application form and my drivers abstract that I would obtain or submit on the date indicated below would be no different than the last Enhanced Police Information Check and/or Criminal Record Check and/or Vulnerable Sector Check and Screening Disclosure and Application form and drivers abstract. I understand that if there have been any changes, or if I suspect that there have been any changes, it is my responsibility to obtain and submit a new Enhanced Police Information Check and/or Criminal Record Check and/or Vulnerable Sector Check and Screening Disclosure and Application form or my drivers abstract.

I recognise that if there have been changes to the results available from the Enhanced Police Information Check and/or Criminal Record Check and/or Vulnerable Sector Check and Screening Disclosure and Application form or my drivers abstract and that if I submit this form improperly, then I may be subject to disciplinary action and/or the removal of volunteer responsibilities or other priviledges at the discretion of the Screening Committee.
Todays Date*

MonthDayYear
Date
Signature*
Screening Disclosure

Note: Intentional omission of truthful information may result in the loss of responsibilities or other privileges.
Should be Empty:

RCA Umpire Screening Renewal Form

Screening Disclosure