Screening Disclosure Form

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(dd/MM/yyyy)








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 Swim Alberta's Screening Policy.

Conviction


Current Criminal Charges


Findings/Settlement
(yyyy)


Settlement Agreement
(yyyy)


Dismissal
(dd/MM/yyyy)


National Discipline
(dd/MM/yyyy)


Disciplined by an Independent Body
(yyyy)

Certification
I hereby certify that the information contained in this application is accurately, correctly, truly and completely represented. By completing and submitting this membership application, I agree to abide by the Swim Alberta's Bylaws and policies as they relate to membership, and to be governed by the policies of Swim Alberta.

I further certify that I will immediately inform Swim Alberta of any changes in circumstances that would alter my original responses to the Registration and Screening Disclosure Form.  Failure to do so may result in termination of membership.
(dd/MM/yyyy)


PRIVACY STATEMENT
  • In order to actively coach in Canada, a Swim Alberta Coach must be registered with Canadian Swim Coaches Association (CSCA) and Swimming Canada (SC). In order to facilitate full compliance, the Swim Alberta Coach membership database will be shared with SC and CSCA to ensure each individual actively coaching within Canada has been duly registered. Your completion of this Registration Membership Form implies and confirms your consent to such disclosure.
  • Privacy Statement: By completing and submitting this Screening Disclosure Form, you consent and authorize Swim Alberta to collect, use and disclose your personal information, including all information provided on the Screening Disclosure Form, for the purpose of screening, implementation of the Swim Alberta Screening Policy, administering membership services and communication with other organizations in Canada, including Swimming Canada, National Sport Organizations, Provincial Sport Organizations, Sport Clubs, and other organizations involved in the governance of the sport of swimming or the profession of coaching. Swim Alberta does not distribute personal information for commercial purposes.
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