Cadets Online: St. John Instructions - Part II

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ST. JOHN CANADA INSTRUCTIONS

2-9-2ap3

(Letterhead)

Sample

AUTHORIZATION FOR POLICE RECORDS CHECK

This request is for a volunteer position with the St. John Ambulance Brigade.

I, the undersigned authorize the local police to release to St. John Ambulance, full disclosure of police information relating to criminal charges and convictions recorded in my name for which a pardon has not been granted.

Please Print

Surname						Given Names
Maiden name or other names used (if applicable)						Place of Birth
Date of Birth	YY	MM	DD	Sex	Telephone (Res) ( )			Driver’s License Number
ADDRESS
						City	Province	Postal Code

(PROVIDE PREVIOUS ADDRESS IF YOU DID NOT RESIDE AT THE ABOVE ADDRESS FOR MORE THAN FIVE YEARS)

Street

City

Province

Postal Code

Waiver and Release:

I hereby consent to the full disclosure of the following classes of information provided by this process:

A. Criminal Record (Adult)

B. Criminal Record (Young Person).*

C. Records of "Not Guilty by Reason of Mental Competence".

D. Pending charges and/or complaints under Federal Statutes

E. Pending charges and/or complaints under the "Child & Family Services Act".

F. Record(s) of convictions for offences under the "Child & Family Services Act".

G. Record(s) of traffic accidents/convictions

*Pursuant to section 44(1) of the Young Offenders Act, a young offender record can be made available to the young person to which the record relates and for the purpose of granting a security clearance in accordance with section 44(1)(i) Young Offenders Act.

I hereby release St. John Ambulance, the local police and any other police authorities, from any liability for such disclosure. I understand that this check may involve fingerprinting for the purpose of verification of my identity. I also consent to this procedure should it be required.

Note: The information provided does not necessarily mean the applicant will be disqualified from the position by St. John Ambulance.

Signed this __________ day of _____________________ 19 _____

_____________________________________________

Signature of Applicant

_____________________________________________

Signature - St. John Ambulance Witness

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For Police Use Only

Information Request about St. John Instructions - Part II