Helping H

ands, Giving H

earts

STEPS FOR NEW VOLUNTEERS: RSVP for the upcoming Volunteer Orientation Session held the last Wednesday of every

month at 1:30 in the Volunteer Services Office or complete the online orientation and submit the re-view form along with your other paperwork. Visit www.qhc.on.ca for online orientation.

Provincial law mandates that anyone working/ volunteering in the hospital must have health screening completed including TB testing and proof of immunization. An Occupational Health form will be given out at the Orientation Session or can be obtained on the QHC website to take to your family doctor or to the health unit. There may be a fee for this service.

New volunteers 18 years and older must provide the BGH Auxiliary with an incident-free police background check.

All new volunteers become members of the BGH Auxiliary. There is a $5 membership fee. As an Auxiliary member you’re invited to all general Auxiliary meetings/events and receive the Bulletin newsletter.

All new volunteers purchase an Auxiliary smock to wear at all times while volunteering. Cost is $20.

RSVP for Orientation: 613-969-7400 ext. 2297

Make Your Impact:

Join the BGH auxiliary.

Volunteer Activities Include:

Oncology Maternity Rec Therapy– Mental Health Rec Therapy– Rehabilitation Rec Therapy– Complex Care Emerg Ambassador Day Surg Ambassador Main Entrance Ambassador Breast Screening Clinic Host Library Cart Palliative Care—Hospice Quinte Family Care Rooms Opportunity Shop Aroma Café—HELPP Lottery Coffee Bar Corridor Café Gift Shop Corner Store Office Assistant Fundraising Special Events Governance

Giving your time in support of the hospital impacts everyone, of all ages and circumstance. The BGH Auxiliary offers diverse and

exciting volunteer opportunities to invest your time to healthcare.

Opportunity Shop: Located at Market Square, this second hand shop raises funds for the Auxiliary. Volunteers sort and price donations, work cash and provide exceptional customer service.

Gift Shop: Located at the Main Entrance of BGH, volunteers provide courte-ous customer service, arrange shelves and conduct sales.

Corner Store: Located just inside the Main Entrance, volunteers work at cash, update inventory and provide exceptional customer service.

Aroma Café: Located at the Sills Entrance, volunteers provide visitors with information and directions as well as selling refreshments, snacks, reading materials and HELPP Lottery Tickets.

Corridor Café: Located on the third floor of BGH, volunteers provide courteous service, assist with food preparation if needed, clean tables and

work at cash.

Main Entrance Ambassador: Stationed at the information desk, volun-teers help patients and visitors find their way around the hospital and answer requests about various departments.

Emergency Department Ambassador: Volunteers interact with patients and families in the emerg, direct or assist patients as appropriate;

reassure and comfort patients; attend to non-medical needs and maintain communication with families.

Same Day Surgery Ambassador: Volunteers act in a host capacity for those coming into day surgery, provide non-clinical information to patients and family members and provide directions for those looking for other clinics and services on Quinte 1.

OSBP (Breast Screening Clinic): Volunteers act in a host manner to women coming in for mammograms, showing the patient to the change area.

Pet Therapy: Pet therapy-certified dogs and owners visit patients to provide social interaction. All dogs must be certified.

Join the Belleville General Hospital Auxiliary!

Palliative Care Service: Volunteers establish a supportive relationship with patients facing end of life. Partnership with Hospice Quinte – all volunteers interested are referred to this agency.

Family Care Rooms: Volunteers help maintain two rooms allocated to families with loved ones in critical/palliative condition within the hospital so they can remain nearby their loved one.

Oncology: Volunteers act as a host for the clinic distributing information about Canadian Cancer Society services, preparing coffee, restocking nutritional supplies and preparing patient packages for use by nurses. In addition to QHC orientation, volunteers take a one hour orientation with the Canadian Cancer Society.

Maternity/Pediatrics: Volunteers provide assistance with a couple of “housekeeping” jobs, occasionally help new moms who wish to shower, etc. by offering to look after their baby, and assist families with the care of sick children who have been admitted.

Maternity Tour Guide: Volunteers provide tours of Quinte 7 (Maternity) for expectant parents.

Library Cart: Volunteers supply patients, visitors and family members with books and magazines on a free lending basis.

Recreation Therapy– Rehab Day Hospital : Volunteers act in a host and support capacity for patients participating in group programs.

Recreation Therapy– Mental Health Inpatient Unit: Volunteers act in a host and support capacity for patients participating in group programs.

Recreation Therapy- Complex Continuing Care: Volunteers help with small group activities and games with long-term care patients and provide one-to-one companionship.

Volunteer Services Office Assistant: Field inquiries from individuals interested in volunteering, answer phones, take memberships, etc.

Governance, Fundraising and Special Events: Volunteers sit on the board and committees to help with Auxiliary operations and projects.

(613) 969-7400 ext. 2297 bgauxiliary@qhc.on.ca www.qhc.on.ca

The BGHA provides a variety of volunteer services for the patients and staff of Quinte Health Care Belleville General. Its fundraising projects are designed to augment the equipment fund of QHC-BG.

Belleville General Hospital Auxiliary Volunteer Application

Name: ____________________________________________________________ Date: ________________ First Name Initial Last Name

Address: __________________________________________________________________________________ Street No. Street Name Apt / Unit No.

___________________________________________________________________________________ P.O Box City / Town Postal Code

My current occupation is: ___________________________ □ Retired □ Student

Student Volunteer Commitment: Due to the time and effort it takes to screen and train student volunteers, we

encourage you to do more than your 40 hours of service required. 100 hour minimum recommended. Thank you.

Check one if applicable: □ Summer Student only □ I intend to do 40 hours only

Sex: □ Male □ Female

Home Phone #: ___________________ Email (H): __________________________________

Work Phone #: ___________________ Email (W): _________________________________

Best time to call? □ A.M. □ P.M. Cell Phone #: _______________________________

Why do you want to volunteer with the Belleville General Hospital Auxiliary?

____________________________________________________________________________________________

____________________________________________________________________________________________

What skills or experience might you be able to offer? (Check all that apply):

□ Knowledge of retail sales □ Musical skills (eg: piano) □ Sewing, knitting, etc. (list below)

□ Knowledge and experience in business and management □ Experience in governance on Boards and committees □ Understanding of fiscal and financial matters □ Understanding of legal matters □ Knowledge and experience in human resource management

List any additional skills you have: ______________________________________________________________________

_____________________________________________________________________________________________

Employment/Training Background (Please attach Resume if available):

_____________________________________________________________________________________________________________________

_____________________________________________________________________________________________________________________

Availability: What days of the week and times are you available to volunteer?

______________________________________________________________________________

Please take a moment to review the many volunteer opportunities available, outlined in the

BGH Auxiliary Volunteer Brochure. What are your top two areas of interest?

1. ______________________________________ 2. _________________________________

Would you be willing to volunteer in any of the following ways? (Check one):

□ On the BGHA Board □ As a Committee Convener (team leader) □ As a member on a committee □ On special events □ On a fundraising event

□ A Board of Directors chart requested with the Application

Comments: ______________________________________________________________

I will abide by the rules and regulations of the Belleville General Hospital Auxiliary.

Signature of Volunteer: _________________________________ Date: ___________________

Reference Check Permission

I, _________________________________, give the BGH Auxiliary permission to contact the

2 references listed below to discuss my suitability as a volunteer within the hospital.

Signature: ____________________________________ Date: _________________________

List 2 persons who have knowledge of your character and/or experiences. Your references should be

people who know you through different relationships and/or situations. For example: employer (paid or

volunteer position), co-worker, teacher, etc. No family members please.

Reference #1

Name: ________________________________________________________________________ First Name Last Name

Phone or Email: ___________________________ Cell Phone #: ________________________

Best time to call? □ A.M. □ P.M. Relationship to applicant: _____________________

Reference #2

Name: ________________________________________________________________________ First Name Last Name

Phone or Email: ___________________________ Cell Phone #: ________________________

Best time to call? □ A.M. □ P.M. Relationship to applicant: _____________________

For Office Use Only Below is an intake checklist for new volunteers. Check each item as the steps are completed.

□ Occupational Health clearance received □ Incident-free police check received □ References checked □ ID badge issued □ Smock □ Membership □ Placement date ___________________ with ______________________________________ □ Follow-up one month later □ Filed Revised Feb 2012

Volunteering at Quinte Health Care

Please sign and return this form with your application to the Volunteer Office.

1. Release and Waiver of Liability:

I understand that Quinte Health Care Corporation and the four Auxiliaries associated with

QHC (Belleville, Trenton, Prince Edward County and North Hastings) disclaims any

responsibility for any losses or injuries to me, my family, and/or my property.

In consideration of Quinte Health Care Corporation and the four Auxiliaries associated

with QHC, permitting me to volunteer, I hereby accept all risks of loss, injury, or damage

to me, my family or my property, and exempt Quinte Health Care and the four

Auxiliaries associated with QHC, its directors, officers, agents, employees, management,

physicians and any other representatives.

In signing this waiver, I do forever release, covenant to hold harmless, and indemnify

Quinte Health Care Corporation and the four Auxiliaries associated with QHC, its

directors, officers, agents, employees, management, physicians and any other

representatives, from any and all actions, causes of actions, claims, demands, damages,

costs, losses, expenses on account of, or in any way arising out of, directly or indirectly,

all personal injuries or property damages which I may now or hereafter may have,

resulting from my voluntary performance of services.

2. Accessibility, Confidentiality & Hand Hygiene:

In addition, I have reviewed and understand the “Making Volunteer Services Accessible”

section of the Volunteer Handbook as well as the sections explaining confidentiality and

hand hygiene: I agree to abide by these sections.

NAME OF VOLUNTEER (Please Print): _________________________________________

Date: _________________________________________

Signature of Volunteer (if 18 or Over): _________________________________________

Signature of Guardian (if Under 18): _________________________________________

Revised Jan 2012

Dear Health Care Practitioner:

This patient is interested in volunteering at Quinte Health Care.

NAME ______________________________________ HOME PHONE (________)_____________________

In order to ensure the safety of our patients, the Ontario Hospital Association (OHA) outlines mandatory

screening standards for the diseases listed below and compliance is required by all persons carrying out duties in

the hospital environment. These standards must be met prior to a person commencing volunteer work at Quinte

Health Care.

1. Volunteers Must Have Immunity to:

Rubella Mumps Measles Varicella / Zoster (Chicken Pox)

To meet OHA standards, the following are acceptable as proof of immunity:

a. Documented evidence of immunity from vaccination; OR

b. Laboratory evidence of immunity; OR

c. For Varicella/Zoster only, definite history of the disease.

2. Tuberculin Testing:

To meet OHA standards, volunteers must be clear of active Tuberculosis and

the following TB screening is required:

a. If your patient’s tuberculin status is unknown, has been identified as tuberculin negative in the past or

has been given a BCG vaccination in the past, a two-step Mantoux skin test with PPD/5TU must be

administered UNLESS he/she has:

Documented evidence of a prior two-step test, OR

Documentation of a negative PPD within the 12 months preceding this placement, OR

Two or more documented PPD at any time but the most recent was more than 12 months

preceding this placement,

in which case a single-step test must be given.

b. If your patient has had a positive Mantoux test in the past, he/she must have a chest x-ray within the

12 months preceding this placement instead of a tuberculin skin test.

3. Influenza Shot: It is strongly suggested that volunteers have an influenza shot.

Walsh & Associates

Occupational Health Services

Occupational Health & Safety Department Communicable Disease Surveillance Program

VOLUNTEER MEDICAL FORM

IMPORTANT:

Please do not provide health/medical records or

additional notes or information of any kind with this form.

XI HEREBY CERTIFY THAT THE ABOVE VOLUNTEER HAS IMMUNITY TO RUBELLA, MUMPS, XMEASLES AND VARICELLA / ZOSTER, AND HAS COMPLETED TB TESTING WITH RESULTS XSHOWING THAT HE / SHE IS CLEAR OF ACTIVE TUBERCULOSIS.

Health Care Practitioner’s Name (print): ___________________________________________________

Designation (check one): Physician R.N.E.C. R.N. R.P.N.

Signature: __________________________________ Date: __________________________________

Address: ____________________________________________ Telephone: _____________________

Important Information for Volunteers

This form can be completed by your health care practitioner or taken to your health unit.

This form must be completed in FULL and signed by your health care practitioner in order for us to

process your volunteer file. After receiving your completed application package, a volunteer from the

Auxiliary Office will contact you regarding possible volunteer opportunities.

Please do not submit medical results, immunization records or notes of any kind with this form. You are only required to have your health care practitioner sign the bottom of Medical Form that you

have immunity to Rubella, Mumps, Measles, Chicken Pox, have had the required TB testing and are clear

of active Tuberculosis.

Please note that because TB testing involves 4 visits to your health care practitioner, it may take several

weeks to complete. We encourage you contact your health care practitioner or a health unit as soon as

possible.

Visit 1 – to have your first TB skin test

Visit 2 – to have your first TB skin test read

Visit 3 – to have your second TB skin test

Visit 4 – to have your second TB skin test read

To meet the Ontario Hospital Association’s screening standards for Measles, assumption of

immunity for persons born before 1970 is NOT acceptable for anyone carrying out duties in the hospital

environment.

If you have any further questions about this form, please contact the Quinte Health Care Volunteer Office

at 613-969-7400, ext. 2075.

Thank you for your interest in volunteering with us!

265 Dundas Street East, Belleville ON K8B5A9

(613) 969-7400 ext. 2297

Date: ___________________________

Re: Request for Police Background & Vulnerable Sector Screening

Dear Sir/Madame:

________________________________ has applied for a volunteer position within

a Quinte Health Care Hospital Auxiliary. We require that all new volunteers have

a police background check and vulnerable sector screening before beginning any

voluntary role within the hospital or and/or Auxiliary Services.

Thank you very much for your time.

Sincerely,

Catherine Walker

Volunteer & Spiritual Care Liaison

Quinte Health Care

cwalker@qhc.on.ca

(613) 969-7400 ext. 2689

Belleville Police Service

Criminal Record Check Application with Vulnerable

Sector Screening

Belleville Police Criminal Record Check Service™

To make a request for the Belleville Police Service to perform a Criminal Record Check for EMPLOYMENT or

Volunteer (payment required) purposes, you have two options:

• The online Criminal Record Check service (requires a $30.00 pre-payment made with VISA or

MasterCard), or;

• Download the Criminal Record Check Request Form online from the Belleville Police Service web

site and/or attend the Belleville Police Service at 93 Dundas Street East in person to fill out the

Form and submit it to our Records Office personnel (requires a $30.00 payment). Pre-payment in

person must be made with cash.

• Free Volunteer Criminal Record Checks will only be processed during the designated Free dates

as listed on the “Events” section of our website at www.police.belleville.on.ca .

Notice of Mandatory Identification Requirements

Two pieces of identification are mandatory, and must be provided at pick up, in order to have a

background check processed as follows:

• One piece has to be a government issued photo ID such as, but not limited to, a driver’s licence,

passport, citizenship card, permanent resident card, certificate of Indian Status,

federal/provincial/municipal employee card, military family identification card.

• The second piece of ID has to have your name on it (photo not required), such as but not limited

to, another government issued photo ID as per above, a birth certificate, library card, student

card.

Do you need a Criminal Background Check (CBC) for employment or volunteer purposes?

CBCs are often requested by individuals who wish to work or volunteer for an organization that requires a

Criminal Background Check prior to employment. CBC information may include:

• Criminal record information

• Information regarding current status of court cases where the applicant is an accused currently

before the courts

Both a Criminal Record Check Request and a Vulnerable Sector search MAY include charges which are

pending before the courts or charges where the applicant was not fingerprinted.

 

Vulnerable Sector Screening IMPORTANT: Please give careful consideration to completing the optional Part 3 (Consent For a Criminal Record

Check and Disclosure For a Sexual Offence For Which a Pardon Has Been Granted or Issued) of the online form. It

may be required if you are going to be working or volunteering in an area where you are in contact with vulnerable

people. A vulnerable person is defined as a person who, because of their age, a disability, or other circumstances,

whether temporary or permanent are:

1. in a position of dependence on others, or

2. are otherwise at a greater risk than the general population of being harmed by a person in a position of

authority or trust relative to them.

The requirement for this part of a background check is determined by the agency you may be working and/or

volunteering with.

The Belleville Police Service can only complete a Vulnerable Sector Screening for residents of the City of

Belleville. If you are a non resident of the City of Belleville you must make this application to the police service

that is responsible for policing in your jurisdiction. If through the process of completing the Criminal Record &

Vulnerable Sector Screening request, the Belleville Police Service determines the home address given is outside the

City of Belleville they will process and complete the Criminal Record Check as requested and charge you

accordingly however this will NOT include the Vulnerable Sector Screening. Belleville Police will notify you in this

regard at the time you attend to pick up the Criminal Record Check.

If through the process of completing the Criminal Record & Vulnerable Sector Screening request, the Belleville

Police Service determines the home address given is outside the City of Belleville they will process and complete

the Criminal Record Check as requested and charge you accordingly however this will NOT include the Vulnerable

Sector Screening. Belleville Police will notify you in this regard at the time you attend to pick up the Criminal

Record Check.

What Sections to Complete:

1) Criminal Record Check only – Section 1

2) Criminal Record Check with Vulnerable Sector Screening – Sections 1 and 2

3) If you are declaring you have a Criminal Record – Sections 1 and 3 (and 2 if VSS also

required)

NOTE: Once the application has been completed the Belleville Police Service will retain the application and result

documents for 60 days. These documents will be destroyed if they have not been ‘picked up’ within this time

frame.  

BELLEVILLE POLICE SERVICE SECTION 1 93 Dundas Street East Belleville, Ontario, K8N 1C2 APPLICATION FOR POLICE (613) 966-0882 RECORD CHECK

DECLARATION of Criminal

Record

I do have a Criminal Record

I do not have a Criminal

Record

NOTE: Information is collected & disclosed in accordance with Section 29(1) and Section 32 MFIPPA FOR OFFICE USE ONLY

PHOTO I.D. CHECKED Drivers License Badge # Other (Specify) RECEIPT # Cash RESULTS

Negative

Based solely on the name(s) and date of birth provided and the criminal record information declared by the applicant, a search of the RCMP National Repository of Criminal Records did not identify any records with the name(s) and date of birth of the applicant. Positive identification that a criminal record does or does not exist at the RCMP National Repository of Criminal Records can only be confirmed by fingerprint comparison

Positive

Based solely on the name(s) and date of birth provided and the criminal record information declared by the applicant, a search of the RCMP National Repository of Criminal Records has resulted in a possible match to a registered criminal record. Positive Identification that a criminal record does or does not exist at the RCMP National Repository of Criminal Records can only be confirmed by fingerprint comparison. As such, the criminal record information declared by the applicant does not constitute a Certified Criminal Record by the RCMP.

Incomplete

Based solely on the name(s) and date of birth provided and the criminal record information declared by the applicant, a search of the RCMP National Repository of Criminal Records could not be completed. Positive identification that a criminal record does not or may not exist requires the applicant to submit fingerprints to the RCMP National Repository of Criminal Records by an authorized police service or accredited private fingerprinting company.

Completed by Member (Signature)

Badge # Date

THIS SCREENING IS NOT INTENDED FOR INDIVIDUALS BEING EMPLOYED AND / OR VOLUNTEERING WITH VULNERABLE PERSONS (See attached Form 1 if applicable) A SEARCH OF THE RCMP NATIONAL REPOSITORY OF CRIMINAL RECORDS WILL BE CONDUCTED BASED ON THE NAME(S), DATE OF BIRTH, AND DECLARED CRIMINAL RECORD HISTORY PROVIDED BY THE APPLICANT. DISCLAIMER: RELEASABLE INFORMATION DOES NOT INCLUDE SUMMARY OF POLICE INFORMATION. THIS DOCUMENT DOES NOT CONSTITUTE A CERTIFIED RECORD BY THE RCMP. THIS DOCUMENT MAY NOT CONTAIN ALL CRIMINAL RECORD CONVICTIONS. A CERTIFIED CRIMINAL RECORD CAN ONLY BE IS2SUED BY CCRTIS BASED ON SUBMISSION OF FINGERPRINTS TO RCMP NATIONAL REPOSITORY OF CRIMINAL RECORDS.

Full Name & Address: Last Name First Name Middle Name

Address

Other Name/Maiden Name/Legal Name Change:

Home Phone No.

Sex

Date of

Birth Day Month Year Place of Birth Height Eye Colour Hair Colour

I have Not Lived anywhere else in the last FIVE years OR List of previous addresses in the last FIVE years:

Reason for Requesting Background Check:

Organization or Agency Requiring Check Contact Name

Contact Phone Number

NOT VALID UNLESS SEALED BY BELLEVILLE

POLICE SERVICE

SECTION 1

BELLEVILLE POLICE SERVICE ACCESS TO INFORMATION WAIVER

I hereby request the Belleville Police Service to undertake a record check on myself by searching all information and records to which it has access and which it considers appropriate for the purpose of the search I agree that my Criminal background information may include:

• Criminal record information

• Information regarding current status of court cases where the applicant is an accused currently before the courts

A Criminal Record Check Request MAY include charges which are pending before the courts or charges where I was not fingerprinted.

WAIVER AND RELEASE

IN CONSIDERATION, of the compliance with the foregoing authorization, I, for myself, my heirs, executors, administrators, successors and assigns HEREBY RELEASE, WAIVE AND FOREVER DISCHARGE the City of Belleville, the Belleville Police Service Board, the Belleville Police Service, the Chief of Police, all their respective agents, officials, servants, contractors, representatives, elected and appointed officials, successors and assigns, and all other police services OF AND FROM ALL claims, demands, damages, costs, expenses, actions, causes of action, whether in law or equity, in respect of death, injury, loss or damage to my person or property HOWSOEVER CAUSED, resulting or alleged to result from my compliance with the foregoing authorization. And I do further waive any and all rights I may now or hereafter have with respect the release of such records of conviction as set out heretofore.

CONSENT INFORMATION

CPIC data banks will be queried based on the name(s), date of birth and declared criminal record history provided by the applicant in the Investigative Data bank files, Ancillary Data bank files, Identification Data bank files, NICHE, PIP, and local police records. As the witness to this application I have confirmed the identification of the applicant.

SIGNATURE OF APPLICANT SIGNATURE OF WITNESS DATE WITNESS (PRINT NAME)

VULNERABLE SECTOR / SCREENING REQUEST SECTION 2 This form is to be used by a person applying for a position with a person or organization responsible for the well- being of one or more children or vulnerable persons, if the position is a position of authority or trust relative to those children or vulnerable persons and the applicant wishes to consent to a search made in criminal conviction records to determine if the applicant has been convicted of a sexual offence listed in the schedule to the Criminal Records Act and has been pardoned

DECLARATION of Criminal

Record

I do have a Criminal Record

I do not have a Criminal

Record

NOTE: Information is collected & disclosed in accordance with Section 29(1) and Section 32 MFIPPA

FOR OFFICE USE ONLY

RESULTS

Negative

Based solely on the name(s) and date of birth provided and the criminal record information declared by the applicant, a search of the RCMP National Repository of Criminal Records did not identify any records with the name(s) and date of birth of the applicant. Positive identification that a criminal record does or does not exist at the RCMP National Repository of Criminal Records can only be confirmed by fingerprint comparison

Positive

Based solely on the name(s) and date of birth provided and the criminal record information declared by the applicant, a search of the RCMP National Repository of Criminal Records has resulted in a possible match to a registered criminal record. Positive Identification that a criminal record does or does not exist at the RCMP National Repository of Criminal Records can only be confirmed by fingerprint comparison. As such, the criminal record information declared by the applicant does not constitute a Certified Criminal Record by the RCMP.

Incomplete

Based solely on the name(s) and date of birth provided and the criminal record information declared by the applicant, a search of the RCMP National Repository of Criminal Records could not be completed. Positive identification that a criminal record does not or may not exist requires the applicant to submit fingerprints to the RCMP National Repository of Criminal Records by an authorized police service or accredited private fingerprinting company.

Completed by Member (Signature)

Badge # Date

A SEARCH OF THE RCMP NATIONAL REPOSITORY OF CRIMINAL RECORDS WILL BE CONDUCTED BASED ON THE NAME(S), DATE OF BIRTH, AND DECLARED CRIMINAL RECORD HISTORY PROVIDED BY THE APPLICANT

Full Name & Address: Last Name First Name Middle Name

Address

Other Name/Maiden Name/Legal Name Change:

Home Phone No.

Sex

Date of

Birth Day Month Year Place of Birth Height Eye Colour Hair Colour

I have Not Lived anywhere else in the last FIVE years OR List of previous addresses in the last FIVE years:

Reason for Requesting Background Check:

Organization or Agency Requiring Check Contact Name

Contact Phone Number

NOT VALID UNLESS SEALED BY BELLEVILLE

POLICE SERVICE

SECTION 2

BELLEVILLE POLICE SERVICE CONSENT TO DISCLOSURE OF PERSONAL INFORMATION

I consent to a search being made in the automated criminal records retrieval system maintained by the Royal Canadian Mounted Police to find out if I have been convicted of, and been granted a pardon for, any of the sexual offences that are listed in the schedule to the Criminal Records Act. I understand that, as a result of giving this consent, if I am suspected of being the person named in a criminal record or one of the sexual offences listed in the schedule to the Criminal Records Act in respect of which a pardon was granted or issued, that record may be provided by the Commissioner of the Royal Canadian Mounted Police to the Solicitor General of Canada, who may then disclose all or part of the information contained in that record to a police force or other authorized body. That police force or authorized body will then disclose that information to me. If I further consent in writing to disclosure of that information to the person or organization referred to above that requested the verification, that information will be disclosed to that person or organization. I also hereby consent to full disclosure of any information from local records of the Belleville Police Service and/or any other police agency(s) to which a copy of this form is provided. I further consent to Probation, prohibition and other judicial orders which are in effect, convictions/pending charges under the Child and Family Services Act. Information contained in the Belleville Police Service reply will be valid as of the date of the search. Personal information contained on this form is collected pursuant to the Police Services Act, s. 41 and is collected for the personal use of the applicant. The results will be forwarded to the applicant at the address noted above. Applicants are responsible for providing these results to requesting organizations.

I agree that my Criminal background information may include:

• Criminal record information

• Information regarding current status of court cases where the applicant is an accused currently before the courts

My Vulnerable Sector Search MAY include charges which are pending before the courts or charges where I was not fingerprinted.

CONSENT INFORMATION To conduct a name-based Vulnerable Sector verification a CPIC Agency must be the police service of local jurisdiction where the applicant resides. A query of the Identification Data bank, including pardoned sex offender records will be conducted. Belleville Police Service will conduct queries based on the name(s), date of birth and declared criminal record history provided by the applicant in local police records, NICHE, PIP, and CPIC Investigation data bank.

RELEASE AND DISCHARGE I hereby release and forever discharge the Chief of the Belleville Police Service and all members and employees of the Belleville Police Service from any and all actions, claims and demands for damages, loss or injury howsoever arising which may hereafter be sustained by myself as a result of the disclosure of the information by the Belleville Police Service.

SIGNATURE OF APPLICANT DATE

BELLEVILLE POLICE SERVICE SECTION 3 93 Dundas Street East Belleville, Ontario, K8N 1C2 (613) 966-0882

DECLARATION OF CRIMINAL RECORD

Applicant must declare all convictions for offences under federal law. Applicant should not declare a conviction for which the Applicant has received a Pardon in accordance with the Criminal Records Act; A conviction where the Applicant was a "young person" under the Youth Criminal Justice Act; An absolute or Conditional Discharge, pursuant to section 730 of the Criminal Code; An offence for which the Applicant was not convicted; Any provincial or municipal offence, and; Any charges dealt with outside of Canada. Declaration of Criminal Record does not constitute a Certified Criminal Record by the RCMP; Declaration of Criminal Record may not contain all criminal record convictions; A Certified Criminal Record can only be issued by CCRTIS based on the submission of fingerprints to the RCMP National Repository of Criminal Records.

I declare the following conviction(s) for offences under Federal Law:

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. I hereby declare that the information provided on this form is true and correct to the best of my knowledge and belief. I acknowledge that this is NOT a Certified Criminal Record. SIGNATURE OF APPLICANT DATE