ANNUAL OFFENCE DECLARATION FORM for Volunteers Please file this information at the school. Legal Surname:

School:

Legal First Name:

Volunteer Position(s):

Male Female Date of Birth (mm/dd/year):

I DECLARE, since the last Criminal Background Check collected by Halton District School Board, or since the last Offence Declaration given by me to Halton District School Board, 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). This declaration is dated at _______________________ this _____ day of (town or municipality)

, 20_____. SIGNATURE:

Volunteers with criminal convictions since the last Criminal Record Check or Criminal Offence Declaration must submit a new, original Criminal Background Check with vulnerable screening prior to volunteering. Information collected on this form is collected under the authority of the S.170 of the Education Act in accordance with the Municipal Freedom of Information and Protection of Privacy Act (MFI PPA) and will be used for volunteer screening and placement.

The completed Offence Declaration must be submitted annually and will be retained with the applicant’s Criminal Records Check