Form CSC/SCC0653e "Visiting Application Form" - Canada

Form CSC/SCC0653e is a Correctional Service Canada form also known as the "Visiting Application Form". The latest edition of the form was released in July 1, 2015 and is available for digital filing.

Download an up-to-date Form CSC/SCC0653e in PDF-format down below or look it up on the Correctional Service Canada Forms website.

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Download Form CSC/SCC0653e "Visiting Application Form" - Canada

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Correctional Service
Service correctionnel
B
PROTECTED
ONCE COMPLETED
Canada
Canada
NOTE: Reference document
CD559
PERSONAL INFORMATION BANK
PUT AWAY ON FILE
Original = Offender VC file
FPS Number
VISITING APPLICATION
Family name (name
of inmate you wish
to visit)
NOTE: Shaded areas are for office use only
Given name(s)
Institution
Region
Date of birth
Completing Operational Unit
IMPORTANT
PLEASE READ THIS FORM CAREFULLY. Answer all questions and sign in the applicable spaces. You are also required to submit with this
application TWO CURRENT PHOTOGRAPHS of yourself (full face view, head and shoulders only) minimum size 5 cm x 3.5 cm (2" x 1 1/2"). Send
your completed application with photographs to the institution (refer to the CSC site for the appropriate address of the institution)
http://www.csc-scc.gc.ca/etablissements/001002-0001-eng.shtml
NOTE: Failure to complete the form fully will result in delays in the visitor approval process. Providing false information is sufficient to deny
access.
PRIVACY ACT STATEMENT
Personal information about you is collected under the authority of the Corrections and Conditional Release Act to review your suitability for visiting privileges
at the CSC. This information is collected, with no obligation on your part, and held in the Visits and Correspondence Bank; however, your refusal to comply
would result in the denial of visiting privileges. This information cannot be disclosed to other persons without your consent EXCEPT where disclosure would
be justified pursuant to one of the paragraphs of subsection 8(2) of the Privacy Act.
INFORMATION ON APPLICANT
Your name
Your date of birth
Your place of birth
Maiden name
Family name
Given names (in full)
YYYY-MM-DD
City/Town
Province/Country
(if applicable)
Your present address
Apt. no.
City
Province
Postal code
No.
Street
Telephone no. where a CSC representative
Motor vehicle
Your telephone no.
Your physical description
could contact you if necessary
licence no.
Colour of
Colour of
Home
Height
Weight
At work OR
Other than home phone
hair
eyes
(
)
-
(
)
-
(
)
-
I am the inmate's
Father
Mother
Spouse
Common-law partner
Brother
Sister
Son
Daughter
I am a victim of an offence committed by this offender
Other (volunteer, friend, cousin, aunt, uncle) (specify type and length of relationship):
Explain if extenuating circumstances
:
Name of person and his/her telephone no. where a CSC
(
)
-
representative may contact in an emergency
Name
(print)
Telephone no.
Are you on another inmate's visiting list?
Are you a volunteer visitor at this or any other institution?
No
Yes
No
Yes
If YES, state inmate's name, your relationship to him/her and which
If YES, state the name of the group or program you take part in and the
institution he/she is in.
institution's name.
CSC/SCC 0653E (R-2015-07) (PDF)
Information may be accessible or protected as required under the provisions
DISTRIBUTION
(Voir CSC/SCC 0653F pour la version française)
of the Access to Information Act and the Privacy Act.
Page 1 of 3
Copy= Security Intelligent Officer
Correctional Service
Service correctionnel
B
PROTECTED
ONCE COMPLETED
Canada
Canada
NOTE: Reference document
CD559
PERSONAL INFORMATION BANK
PUT AWAY ON FILE
Original = Offender VC file
FPS Number
VISITING APPLICATION
Family name (name
of inmate you wish
to visit)
NOTE: Shaded areas are for office use only
Given name(s)
Institution
Region
Date of birth
Completing Operational Unit
IMPORTANT
PLEASE READ THIS FORM CAREFULLY. Answer all questions and sign in the applicable spaces. You are also required to submit with this
application TWO CURRENT PHOTOGRAPHS of yourself (full face view, head and shoulders only) minimum size 5 cm x 3.5 cm (2" x 1 1/2"). Send
your completed application with photographs to the institution (refer to the CSC site for the appropriate address of the institution)
http://www.csc-scc.gc.ca/etablissements/001002-0001-eng.shtml
NOTE: Failure to complete the form fully will result in delays in the visitor approval process. Providing false information is sufficient to deny
access.
PRIVACY ACT STATEMENT
Personal information about you is collected under the authority of the Corrections and Conditional Release Act to review your suitability for visiting privileges
at the CSC. This information is collected, with no obligation on your part, and held in the Visits and Correspondence Bank; however, your refusal to comply
would result in the denial of visiting privileges. This information cannot be disclosed to other persons without your consent EXCEPT where disclosure would
be justified pursuant to one of the paragraphs of subsection 8(2) of the Privacy Act.
INFORMATION ON APPLICANT
Your name
Your date of birth
Your place of birth
Maiden name
Family name
Given names (in full)
YYYY-MM-DD
City/Town
Province/Country
(if applicable)
Your present address
Apt. no.
City
Province
Postal code
No.
Street
Telephone no. where a CSC representative
Motor vehicle
Your telephone no.
Your physical description
could contact you if necessary
licence no.
Colour of
Colour of
Home
Height
Weight
At work OR
Other than home phone
hair
eyes
(
)
-
(
)
-
(
)
-
I am the inmate's
Father
Mother
Spouse
Common-law partner
Brother
Sister
Son
Daughter
I am a victim of an offence committed by this offender
Other (volunteer, friend, cousin, aunt, uncle) (specify type and length of relationship):
Explain if extenuating circumstances
:
Name of person and his/her telephone no. where a CSC
(
)
-
representative may contact in an emergency
Name
(print)
Telephone no.
Are you on another inmate's visiting list?
Are you a volunteer visitor at this or any other institution?
No
Yes
No
Yes
If YES, state inmate's name, your relationship to him/her and which
If YES, state the name of the group or program you take part in and the
institution he/she is in.
institution's name.
CSC/SCC 0653E (R-2015-07) (PDF)
Information may be accessible or protected as required under the provisions
DISTRIBUTION
(Voir CSC/SCC 0653F pour la version française)
of the Access to Information Act and the Privacy Act.
Page 1 of 3
Copy= Security Intelligent Officer
Name
FPS No.
Give the names and ages of any of your children (under the provincial age of
Have you ever been convicted of a criminal offence for which you have not
majority, see CD 559 Visits, Annex B) for whom you wish visiting privileges
been granted a pardon, or an offence for which you have been granted a
(see also section 3 of Acknowledgement and Consent on page 3).
pardon and such a pardon has been revoked?
Date of Birth
Name(s)
Yes
No
(print)
(YYYY-MM-DD)
Are there at present any outstanding charges against you?
Yes
No
Please indicate what document you will be using as identification when
visiting the institution. Give name of document and the registration or other
number appearing on it.
Date received
and
Date application
(YYYY-MM-DD)
Comments
by whom
reviewed
(print)
(YYYY-MM-DD)
Approved
Denied
CORRECTIONS AND CONDITIONAL RELEASE ACT (Excepts)
45. Every person commits a summary conviction offence who:
a)
is in possession of contraband beyond the visitor control point in a penitentiary;
b)
is in possession of anything referred to in paragraph (b) or (c) of the definition “contraband” in section 2 before the visitor control point at a
penitentiary;
c)
delivers contraband to, or receives contraband from, an inmate;
d)
without prior authorization, delivers jewellery to, or receives jewellery from, an inmate; or
e)
trespasses at a penitentiary.
“Contraband” means:
a)
an intoxicant,
b)
a weapon or a component thereof, ammunition for a weapon, and anything that is designed to kill, injure or disable a person or that is altered
so as to be capable of killing, injuring or disabling a person, when possessed without prior authorization,
c)
an explosive or a bomb or a component thereof,
d)
currency over any applicable prescribed limit, when possessed without prior authorization, and
e)
any item not described in paragraphs (a) to (d) that could jeopardize the security of a penitentiary or the safety of persons, when that item is
possessed without prior authorization.
60. (1) A staff member may conduct a frisk search of a visitor where the staff member suspects on reasonable grounds that the visitor is carrying
contraband or carrying other evidence relating to an offence under section 45.
(2) Where a staff member
(a) suspects, on reasonable grounds that a visitor is carrying contraband or carrying other evidence relating to an offence under section 45,
and believes that a strip search is necessary to find the contraband or evidence, and
(b) satisfies the institutional head that there are reasonable grounds
(i)
to suspect that the visitor is carrying contraband or carrying other evidence relating to an offence under section 45, and
(ii)
to believe that a strip search is necessary to find the contraband or evidence, a staff member of the same sex as the visitor may, after
giving the visitor the option of voluntarily leaving the penitentiary forthwith, conduct a strip search of the visitor.
(3)
Where a staff member believes on reasonable grounds that a visitor is carrying contraband or carrying other evidence relating to an offence
under section 45 and that a strip search is necessary to find the contraband or evidence,
(a) the staff member may detain the visitor in order to
(i)
obtain the authorization of the institutional head to conduct a strip search, or
(ii)
obtain the services of the police; and
(b) where the staff member satisfies the institutional head that there are reasonable grounds to believe
(i)
that the visitor is carrying contraband or carrying other evidence relating to an offence under section 45, and
(ii)
that a strip search is necessary to find the contraband or evidence, the institutional head may authorize a staff member of the same
sex as the visitor to conduct a strip search of the visitor.
(4)
A visitor who is detained pursuant to subsection (3) shall
(a)
be informed promptly of the reasons for the detention; and
(b) before being searched, be given a reasonable opportunity to retain and instruct counsel without delay and be informed of that right.
CSC/SCC 0653E (R-2015-07) (PDF)
Page 2 of 3
Name
FPS No.
CORRECTIONS AND CONDITIONAL RELEASE REGULATIONS (Excerpts)
Searches of Visitors
54. (1) A staff member may conduct a routine non-intrusive search or a routine frisk search of a visitor, without individualized suspicion, where the visitor
is entering or leaving the penitentiary.
(2) If a visitor refuses to undergo a search referred to in subsection (1), the institutional head or a staff member designated by the institutional
head may
(a)
prohibit a contact visit with an inmate and authorize a non-contact visit; or
(b)
require the visitor to leave the penitentiary forthwith.
ACKNOWLEDGMENT AND CONSENT
1.
I understand that the Correctional Service of Canada has the sole right to determine my suitability as an inmate’s visitor. I further understand that
approval of visiting privileges is conditional upon satisfactory results of a criminal record name check and I hereby give my consent to the Correctional
Service of Canada to use the information provided on this form to conduct such a check. To this end, I certify that the information I have submitted is
true and accurate to the best of my knowledge, and I agree to notify institutional authorities immediately should there be any changes to that
information. I also give my consent that criminal record name checks be conducted every two years as per CD 559, provided that I continue to
participate in visits. I acknowledge that the submission of false or misleading information or the failure to advise of changes may result in denial or
suspension of my visiting privileges for an indefinite period. Finally, I agree to observe all stated rules, regulations and policies while visiting this
institution and understand that the failure to do so may likewise result in suspension of my visiting privileges for an indefinite period.
2.
I understand that before each visit, I could be subjected to a search as per CCRA and CCRR. Furthermore, I understand that if I refuse to be searched,
I may be denied access to the institution or that a contact visit may be replaced with a non-contact visit.
3.
I understand that my oral, visual or telecommunications with an inmate may be subject to interception.
Name
Signature of applicant
Date
(Print)
(YYYY-MM-DD)
For visitors who wish visiting privileges for their children or wards
4.
a)
In consideration of my child or ward being granted visiting privileges, I consent to a search of his/her person by a walk-through scanner or hand-
held scanning device, and to a search of his/her personal property, in accordance with the procedure outlined in section 60.
b)
I understand that the institution may consider it necessary that my child or ward be subjected to searches as per CD 566-8 Searching of Staff and
Visitors and for this purpose.
I hereby consent to such searches being performed.
OR
I wish to be contacted for my consent prior to such searches being performed.
Furthermore, I require
do not require
That I or another accompanying adult be present when such searches take place.
Name
Signature of parent or legal guardian
Date
(print)
(YYYY-MM-DD)
CSC/SCC 0653E (R-2015-07) (PDF)
Page 3 of 3
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