Screening Disclosure Form
Current Personal Information
NOTE: Intentionally falsifying personal information will be subject to failure of screening requirements as outlined by the Manitoba Lacrosse Association's Screening Policy.
Name:
*
First Name
Middle Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Current Permanent Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number (Primary):
*
Please enter a valid phone number.
Phone Number (Secondary):
*
Please enter a valid phone number.
Email:
*
example@example.com
Club/School/Team:
*
In which role(s) are you participating?
*
Coach
Manager
Official
Administrator
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Previous Personal Information
If applicable
Previous Name:
First Name
Middle Name
Last Name
Previous Address 1:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Previous Address 2:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Screening Disclosure
Note: Failure to disclose a conviction/sanction for which a pardon has not been granted may be considered an intentional omission and subject to failure of screening requirements as required by the Manitoba Lacrosse Association's Screening Policy. A "yes" answer does not necessarily disqualify you, however all information will be considered during the screening process.
Have you ever been convicted of a criminal offence for which a pardon has not been granted?
*
Yes
No
Offence 1
Offence 2
Offence 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
No
If yes, please provide details:
Have you ever been dismissed from a position due to allegations of ethical or moral misconduct?
*
Yes
No
If yes, please provide details:
Have you ever been disciplined or sanctioned by an independent body (sport body, private tribunal, government agency, etc.) for which a pardon has not been granted?
*
Yes
No
If yes, please provide details:
Have you ever been removed from a position of trust with children or vulnerable persons due to concerns about your conduct (e.g., volunteer roles, employment)?
*
Yes
No
If yes, please provide details:
Have you ever been found guilty of child abuse or neglect by a court of law or administrative body?
*
Yes
No
If yes, please provide details:
Are you currently registered on any child abuse registries in Canada or any other country you have resided in?
*
Yes
No
If yes, please provide details:
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References
Please provide the contact information for two professional references who can speak to your character and suitability for working with children. References should not be family members or close personal friends.
Reference 1:
*
Reference 2:
*
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Certification
I hereby certify that the information contained in this application is accurate, correct, truthful, and complete. I further certify that I will immediately inform the Organization of any changes in circumstances that would alter my original responses to this Screening Disclosure Form. Failure to do so may result in termination of membership and/or further discipline.
Signature
*
Privacy Statement
By completing and submitting this Screening Disclosure Form, you consent and authorize the Organization to collect, use, and disclose your personal information, including all information provided on the Screening Disclosure Form for the purposes of screening, implementation of the Manitoba Lacrosse Association’s Screening Policy, administering membership services, and communicating with other Provincial Sport Organizations, Host Societies, and other organizations involved in the governance of the sport. The Manitoba Lacrosse Association does not distribute personal information for commercial purposes.
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