OFFENCE DECLARATION Offence Declaration Form Name* First Last Who is your Mentoring Coordinator? (BBBS Staff Person)*If you are uncertain, please select Volunteer Intake Adrianna Kipp Alexis Gardner Alysha Vivian Brooke MacDonald ( In-School Salt Spring Island) Candace Johnson (In-School Comox) Ezra Loggin Fiona Hawes (in-School Victoria) Kait Burns (Go Girls) Kathryn Ebert (In-School Sooke and Marigold) Volunteer Intake I DECLARE,*since the last Criminal Records Check (or Vulnerable Sector Check) provided to Big Brothers Big Sisters of Victoria and Area, or since the last Offence Declaration Form submitted to Big Brothers Big Sisters of Victoria and Area, that: 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,*that since the last Criminal Records Check (or Vulnerable Sector Check) provided to Big Brothers Big Sisters of Victoria and Area, or since the last Offence Declaration Form submitted to Big Brothers Big Sisters of Victoria and Area, that: 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,*that since the last Criminal Records Check (or Vulnerable Sector Check) provided to Big Brothers Big Sisters of Victoria and Area, or since the last Offence Declaration Form submitted to Big Brothers Big Sisters of Victoria and Area, that: I have no charges pending under the Criminal Code of Canada up to and including the date of this declaration.I DECLARE,*that since the last Criminal Records Check (or Vulnerable Sector Check) provided to Big Brothers Big Sisters of Victoria and Area, or since the last Offence Declaration Form submitted to Big Brothers Big Sisters of Victoria and Area, that: 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,*that since the last Criminal Records Check (or Vulnerable Sector Check) provided to Big Brothers Big Sisters of Victoria and Area, or since the last Offence Declaration Form submitted to Big Brothers Big Sisters of Victoria and Area, that: My driver’s license has not been suspended or restricted for any reason.Please check the appropriate box:* There have been no occurrences as described above since my last Criminal Record Check or Offence Declaration Form. All reportable matters as described above were discussed with Agency Staff and/or the Executive Director at the time of the occurrence(s). Signature*By entering in my name, 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 lead to a review of my continued service with Big Brothers Big Sisters of Victoria and Area. First Last Witness*By entering your name you are confirming you witnessed the person (named above) sign the Offence Declaration Form. First Last Date* MM slash DD slash YYYY
