Volunteer Declaration Form | Kemp Care Network

Volunteer Offence Declaration

Section 1

Name(Required)

First Last

Position(Required)

Volunteer

Section 2

I DECLARE, since the last criminal record check collected by this hospice, or since the last Offence Declaration given by me to this hospice, that:(Required)

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)

I have been convicted of the following criminal offences under the Criminal Code of Canada for which a pardon under Section 4.1 of the Criminal Records Act (Canada) has not been issued or granted to me.

If convicted, please provide more information (Date, Court Location, & Conviction).

Section 3

I hereby certify that, to the best of my knowledge, the provided information is true and accurate.(Required)

Please type your full name in all capital letters.

Date signed(Required)

City (you reside in)

Name

This field is for validation purposes and should be left unchanged.

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