Job s Daughters International Certified Adult Volunteer Renewal Application CANADA This form may only be used by Certified Adult Volunteers that have current CAV Status on file with the Executive Manager. If your CAV status has lapsed, you must attend a Certified Adult Volunteer (CAV) class again and you must reapply for CAV status using the CAV Application & Profile Form YPP 001 CAN. This form shall be RECEIVED by the Supreme Office at least 30 days PRIOR to your CAV expiration date. It may not be sent sooner than 90 days in advance of your CAV expiration date. Please Type or Print legibly. Pencil entries cannot be accepted. If you need space for further information, please use the back of the form or attach a separate sheet. Personal Data 1. Name: (Last) (First) (Middle Name not just the initial) 2. Address: City: Prov: Postal Code: Home Phone: Work Phone (or daytime number) E-mail address: 3. Bethel No. City: Prov: _ 4. CAV # 5. Current Title in BGC/JGC/GGC/SGC (if any): Updated Profile Information Complete these update questions about personal information changes. Any questions answered YES must be explained in writing. Attach your answers to this form. 6. Since your last CAV certification, have you had your driver s license revoked or suspended for any reason? 7. Since your last CAV certification, were you involved in any motor vehicle accidents that resulted in personal injury or fatality? Page 1 of 6 Revised August 4, 2014 Form YPP 002 CAN
8. Since your last CAV certification, have you been arrested or received a ticket for driving under the influence of alcohol or drugs, drunk driving, reckless driving or careless driving? 9. Since your last CAV certification, has your driving status changed? _ 10. Since your last CAV certification, have you used any illegal drugs, or been treated or hospitalized for drug use? 11. Since your last CAV certification, have you used alcohol excessively or been treated or hospitalized for alcohol use? 12. Since your last CAV certification, have you been accused, charged, arrested or convicted of any crime? 13. Have you ever been removed from a Bethel/Jurisdictional/Grand/Supreme Guardian Council position or has any adverse action, including termination, been taken against you by any YOUTH organization, school, church or day care center while you were an employee or volunteer for such organization or entity? _ 14. To the best of your knowledge and belief, are there any facts or circumstances involving you or in your background that would call into question your suitability for being entrusted with the supervision, guidance and care of young people? 15.. Since your last CAV certification, have you had a name change? NO (If YES, Please list your prior full name) 16.. Since your last CAV certification, have you had an address, phone number or email change? NO (If YES, Please list your prior address) Affirmation of Understand of JDI Youth Protection Standards Read carefully and initial your agreement of the following JDI Youth Protection Standards: I have read, understand and agree to follow the Policy and Guidelines as set forth in the JDI Youth Protection Program & Policy. I understand that I am to report all violations of the JDI Youth Protection Program & Policy as outlined in the Policy. I understand that proper supervision by CAVs is required at all Job s Daughters meetings and activities as outlined in the JDI Youth Protection Program & Policy. Revised August 4, 2014 I understand that in my role as a CAV I am also governed by the Constitution and Bylaws of JDI and the Rules & Regulations of the SGC and my GGC / JGC / BGC. Page 2 of 6 Form YPP 002 CAN
I understand that my use of illegal drugs or alcohol while serving in a CAV capacity OR at a Job s Daughters function with Daughters present is strictly prohibited. I understand that at any time a background check may be obtained by JDI and that any adverse findings may mean the loss of my status as a CAV. I understand that any violation of the JDI Youth Protection Program & Policy may mean the loss of my status as a CAV and that the JDI Board of Trustees is the enforcement authority of the JDI Youth Protection Program. I further understand and authorize JDI to verify the information listed in this CAV Renewal Application. Acknowledgement of CAV Renewal Application I certify that the information provided herein is complete and accurate. I will immediately notify JDI of any changes in that information. I understand that I am not entitled to a position as an officer or volunteer in JDI, and that service in those capacities is a privilege, not a right By placement of my signature on this CAV Renewal Application, I acknowledge my understanding of the JDI Youth Protection Program and Policy and agree to follow it. Signature: Date: This form is to be RECEIVED by the Supreme Office no sooner than 90 days and no later than 30 days PRIOR to your current CAV expiration date in order to be considered valid for processing. Your Certified Adult Volunteer Renewal Application must be signed. Incomplete forms will not be processed. The renewal application fee is $20.00 in US Funds and must accompany this application: - International money order in US Funds for $20.00 and payable to Job s Daughters International - WE CANNOT ACCEPT CANADIAN POSTAL MONEY ORDERS - Or Credit card information provided below Credit Card Information Mastercard or Visa (Check One) Credit Card Number Name as it appears on Card (Print) Expiration Date of Card _ Signature Revised August 4, 2014 Page 3 of 6 Form YPP 002 CAN
Mail your Application and payment to: Job s Daughters International 233 W. 6 th Street Papillion, NE, USA 68046 If you would like notification that you application has been received, enclose a self-addressed stamped postcard. Authorization for Release of Information NOTE: The witness declaration is to be made by a current Executive Council Member of the Bethel you work with or a current Executive Grand/Jurisdictional Guardian Council member of the Province you work in. Revised August 4, 2014 Page 4 of 6 Form YPP 002 CAN
CONSENT TO DISCLOSURE OF PERSONAL INFORMATION (Please Print) (To be completed by applicant ) Surname (Last Name) (Provide previous name(s) prior to application if applicable) First Name Middle Name Maiden Name or Other Surnames Used (if applicable): Place of Birth (Province and Country) Date of Birth Sex Phone # (YEAR-MONTH-DAY) Current Address Number Street Apt/Unit City/Province/Country Postal Code Provide previous addresses, if any, within the last five (5) years Number Street Apt/Unit City/Province/Country Postal Code Number Street Apt/Unit City/Province/Country Postal Code Reason for the Consent: Employment Volunteer Description of Position Note: Information related to this criminal record is collected, retained, and disclosed in accordance with applicable federal, provincial, and municipal privacy legislation. SEARCH AUTHORIZATION: I HEREBY CONSENT TO THE SEARCH OF THE RCMP NATIONAL REPOSITORY OF CRIMINAL RECORDS BASED ON THE NAME(S), DATE OF BIRTH AND DECLARED CRIMINAL RECORD PROVIDED. I UNDERSTAND THAT THE RESULTS MAY BE TRANSMITTED OUTSIDE CANADA TO FOR EMPLOYMENT PURPOSES. A. Criminal Record (Adult) Signed this day of, 20 RELEASE AUTHORIZATION AND WAIVER Authorization to Release Clearance Report. I certify that the information set out by me in this application is true and correct to the best of my ability. I consent to the release of a Criminal Record to CSI Inc. and its partners. (Signature of Applicant) I hereby release and forever discharge all members and employees of the processing 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 information by the processing Police Service to CSI Inc. and its partners. Note: The presence of information does not necessarily mean the applicant will be disqualified from the position by the organization. ORGANIZATION REQUESTING SEARCH 1. 2. Signature of Individual Applicant s ID Type of Photo ID Viewed (Government Issued) and Secondary ID Viewed Printed Name of Individual Witnessing Applicant s ID
CONSENT TO DISCLOSURE OF PERSONAL INFORMATION DECLARATION OF CRIMINAL RECORD INFORMATION APPLICANT MUST DECLARE ALL CONVICTIONS FOR OFFENCES UNDER FEDERAL LAW _ Printed Name of Applicant _ Signature of Applicant Date Signed Year/Month/Day _ Signature of Police Personnel CONVICTION DATE OFFENCE (and POLICE SERVICE if known) LOCATION OF OFFENCE DO NOT LIST ANY OF THE FOLLOWING OFFENCES ON THIS FORM: 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 Discharge 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 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 Record.
PLEASE READ PRIOR TO COMPLETING CONSENTS Instructions for completion of Consent to Disclosure of Personal Information form and Declaration of Criminal Record Information These forms are the only forms that the RCMP and CPIC will allow to be used for conducting name based criminal record checks. Further they will not allow any changes or additions to these forms. 1. Identification of Applicant The top section of this form is for the personal details of the applicant, including surname, first and middle names, maiden or other surnames used, place and date of birth, sex and telephone number. Please include all of your names as some companies will not accept a criminal check if you have not included all names in your application. 2. Current and previous addresses This section is again for the applicant to complete their current and previous addresses for the last 5 years. 3. Reason for consent - This section is for the applicant to indicate if this criminal check is for employment or a volunteer service. The description of position is only for applicants who indicate volunteer on the consent. 4. Search Authorization In this section the applicant must read and understand the consent they are giving and they must date and sign the block to the right of the consent. If the criminal record check is for employment outside Canada, the applicant must indicate the country of employment in the space provided in the first paragraph. 5. Witness Section (Organization Requesting Search) This final section is for the witness signature. The first line, which can be completed by the applicant, is for the name of the company requiring the search. (The employer). The second line is for the signature of the witness who verified the identity of the applicant, by reviewing the two pieces of identification and
comparing to the applicant. The witness will then print their name below their signature. 6. Identification used In this section the witness must indicate which two pieces of identification they reviewed. Below we have identified the only acceptable pieces of photo identification permitted. 7. The Applicant's identity must be verified by client or other person, who is not a family member by comparing 2 pieces of ID, one of which MUST be an accepted government issued photo ID of the applicant and scanned legible copies of both pieces of ID MUST accompany this form. If the copies are not legible, they cannot be processed and they will be returned. 8. Please make sure your ID s are scanned or captured by camera on your cell phone. Remember to disable your flash on your camera. 9. Accepted photo ID - Canadian Driver s License; Canadian Citizenship Card; Firearms Acquisition Certificate; Foreign Driver s License; Permanent Resident (PR) Card; Federal, Provincial or Municipal ID Card; Canadian Passport; Certificate of Indian Status; Military Family ID Card; Foreign Passport; Student Identity Card Foreign Institute; CNIB ID Card Declaration of Criminal Record If you have been convicted of a criminal offence in Canada, then this form must be completed and submitted with your consent. The applicant s printed name and signature are required at the top, along with the date of signature. Please indicate as close as possible the date of the conviction, the offence and the location of the offence is also required. Please read the exemptions at the bottom of the form. If you have any questions or concerns about completing these forms please do not hesitate to contact CSI Screening at csi@csiscreening.com