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.

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

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Correctional Service

Service correctionnel

PROTECTED

ONCE COMPLETED

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

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?

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

PROTECTED

ONCE COMPLETED

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

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?

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

(print)

(YYYY-MM-DD)

Are there at present any outstanding charges against you?

Yes

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:

is in possession of contraband beyond the visitor control point in a penitentiary;

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;

delivers contraband to, or receives contraband from, an inmate;

without prior authorization, delivers jewellery to, or receives jewellery from, an inmate; or

trespasses at a penitentiary.

“Contraband” means:

an intoxicant,

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,

an explosive or a bomb or a component thereof,

currency over any applicable prescribed limit, when possessed without prior authorization, and

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

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.

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.

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

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.

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