Softball Ontario - Screening Disclosure Form
Full Name: (First, Middle, Last) *
Your answer
Position: *
Your answer
Other Names You Have Used:
Your answer
Current Permanent Address:
Street: *
Your answer
City: *
Your answer
Province: *
Your answer
Postal: *
Your answer
Date of Birth: (MM/DD/YY) *
Your answer
Gender: *
Phone: *
Your answer
Email: *
Your answer
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 Softball Ontario.
1. I DECLARE, since the last Criminal Background Check collected by Softball Ontario, or since the last Screening Disclosure Form submitted by me to Softball Ontario, that: *
Required
Have you ever been convicted for a crime for which a pardon has not been granted, including possession or trafficking of an illegal substance? *
If you answered yes to the above question, please describe below for each conviction:
Name or Type of Offense:
Your answer
Name and Jurisdiction of Court/Tribunal:
Your answer
Year Convicted:
Your answer
Penalty or Punishment Imposed:
Your answer
Further Explanation:
Your answer
Are criminal charges or any other sanctions, including those from a sport body, private tribunal or government agency, currently pending or threatened against you? *
If you answered yes to the above question, please describe below for each pending charge:
Name or Type of Offense:
Your answer
Name and Jurisdiction of Court/Tribunal:
Your answer
Year Convicted:
Your answer
Penalty or Punishment Imposed:
Your answer
Further Explanation:
Your answer
Has any civil court made a finding, judgement or ruling against you, relevant to the profession of coaching/officiating or the sport of softball? *
If you answered yes to the above question, please describe each finding, judgement or ruling below:
Type of Offense or Finding:
Your answer
Year of Offense:
Your answer
Penalty or Punishment Imposed:
Your answer
Further Explanation:
Your answer
Have you ever been dismissed from a coaching /officiating position due to allegations of ethical or moral misconduct? *
If you answered yes to the above question, please describe below:
Name of Applicable Organization:
Your answer
Date of Dismissal:
Your answer
Reason for Dismissal:
Your answer
Have you ever been disciplined or sanctioned by a sport governing body outside Canada or by any other body within Canada that governs the sport of softball or the coaching/officiating profession? *
If you answered yes to the above question, please describe below:
Name of Applicable Organization:
Your answer
Date of Discipline or Sanction:
Your answer
Reason for Discipline or Sanction:
Your answer
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 Softball Ontario of any changes in circumstances that would alter my original responses to this Screening Disclosure Form. Failure to do so may result in termination.
Acknowledgement by checking the "I Agree" box, the Parties are consenting to the use of their electronic agreement in lieu of an original signature on paper. Electronic Consent. *
Required
Full Name: *
Your answer
Date: *
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