OFFENCE DECLARATION Offence Declaration Form "*" indicates required fields Name* First Last Who is your Mentoring Coordinator? (BBBS Staff Person)*If you are uncertain, please select Volunteer Intake Alexis Gardner Alysha Vivian Brooke MacDonald ( In-School Salt Spring Island) Candace Johnson (In-School Comox) Kait Burns (B You) Kate Hadwin (In School Victoria) Becca Bosworth (B You) Julia Ross Sultan Sadaka (In-School Sooke/West Shore) Volunteer Intake Alexis Miedema I DECLARE,*I DECLARE, since the last Criminal Records Check* provided to BIG BROTHERS BIG SISTERS OF VICTORIA CAPITAL REGION, or since the last Annual Offence Declaration Form submitted to BIG BROTHERS BIG SISTERS OF VICTORIA CAPITAL REGION, that: *Includes a Vulnerable Sector Check for those who are in a position of trust. I have no convictions under the Criminal Code of Canada up to and including the date of this declaration for which a pardon has not been issued or granted under the Criminal Records Act (Canada).I DECLARE,*I DECLARE, since the last Criminal Records Check* provided to BIG BROTHERS BIG SISTERS OF VICTORIA CAPITAL REGION, or since the last Annual Offence Declaration Form submitted to BIG BROTHERS BIG SISTERS OF VICTORIA CAPITAL REGION, that: *Includes a Vulnerable Sector Check for those who are in a position of trust. I have no pardons related to sexually based offences up to and including the date of this declaration under the Criminal Records Act (Canada).I DECLARE,*I DECLARE, since the last Criminal Records Check* provided to BIG BROTHERS BIG SISTERS OF VICTORIA CAPITAL REGION, or since the last Annual Offence Declaration Form submitted to BIG BROTHERS BIG SISTERS OF VICTORIA CAPITAL REGION, that: *Includes a Vulnerable Sector Check for those who are in a position of trust. I have no charges pending under the Criminal Code of Canada up to and including the date of this declaration.I DECLARE,*I DECLARE, since the last Criminal Records Check* provided to BIG BROTHERS BIG SISTERS OF VICTORIA CAPITAL REGION, or since the last Annual Offence Declaration Form submitted to BIG BROTHERS BIG SISTERS OF VICTORIA CAPITAL REGION, that: *Includes a Vulnerable Sector Check for those who are in a position of trust. I have not been the subject of any criminal investigation or allegation, any child welfare investigation or allegation, nor have I had any charges brought against me, even if the charges are pending.I DECLARE,*I DECLARE, since the last Criminal Records Check* provided to BIG BROTHERS BIG SISTERS OF VICTORIA CAPITAL REGION, or since the last Annual Offence Declaration Form submitted to BIG BROTHERS BIG SISTERS OF VICTORIA CAPITAL REGION, that: *Includes a Vulnerable Sector Check for those who are in a position of trust. My driver’s license has not been suspended, restricted, or revoked for any reason.Please check the appropriate box:* There have been no changes to the information described above since my last Criminal Record Check* or submission of an Annual Offence Declaration Form, OR All reportable matters as described above were discussed with Agency Staff and/or the Executive Director at the time of the occurrence(s). *Includes a Vulnerable Sector Check for those who are in a position of trust.Signature*By signing this form, I consent to the collection and use of my personal information disclosed herein by authorized personnel at BIG BROTHERS BIG SISTERS OF VICTORIA CAPITAL REGION and Big Brother Big Sisters of Canada (BBBSC) for the purpose of assessing my continued involvement with the agency. I understand that I may withdraw consent at any time; however, withdrawal may affect my involvement with BIG BROTHERS BIG SISTERS OF VICTORIA CAPITAL REGION. I hereby attest that the information disclosed herein is true, complete and accurate to the best of my knowledge and belief. I understand that failure to complete an accurate and truthful Offence Declaration will affect my involvement with BIG BROTHERS BIG SISTERS OF VICTORIA CAPITAL REGION. First Last Date* MM slash DD slash YYYY EmailThis field is for validation purposes and should be left unchanged.
