"Consent to a Criminal Record Check for Working With Children and/or Vulnerable Adults" - British Columbia, Canada

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Consent to a Criminal
Record Check
For working with children
and/or vulnerable adults
Schedule Type: B – APPLICANT TO/CERTIFICATE HOLDER WITH MINISTRY OF EDUCATION
Pursuant to the Criminal Records Review Act, all applicants to and certificate holders with the Ministry of Education must undergo a criminal
record check, which includes a vulnerable sector check, every five years. The Teacher Regulation Branch of the Ministry of Education
facilitates this requirement by collecting and submitting your consent to the Criminal Records Review Program of the Ministry of Public
Safety and Solicitor General who will perform the criminal record check.
IMPORTANT: Please complete this form using a dark ink pen, printing clearly and carefully. There may be a delay in processing
if the form is submitted incomplete or incorrectly, or if information cannot be read. When the form is completed and signed by you,
please forward it to the Teacher Regulation Branch by mail, or as a scanned email attachment (trb.certification@gov.bc.ca).
PART 1 – APPLICANT/CERTIFICATE HOLDER INFORMATION
File or Certificate Number:
Surname
Full First
Full Middle
Male
Female
Birth Date (YYYY/MM/DD)
Gender
Birth Place
(City, Province/State, Country)
OTHER NAMES USED OR HAVE USED: (e.g. alias, maiden name, birth name, or previous married name)
Other Surname(s)
Other First Name(s)
Other Middle Name(s)
1.
2.
3.
Mailing Address
City
Province
Country
Postal Code
BC Driver's Licence Number: DL
(Please leave blank if you don’t have a BC Driver’s Licence.)
Contact Phone
Email Address
PART 2 – ORGANIZATION INFORMATION – For Office Use Only
Regulatory Body Name: Teacher Regulation Branch, Ministry of Education
ID Number: 15/606188
Mailing Address: 400 – 2025 W Broadway
City: Vancouver
Province: BC
Country: Canada
Postal Code: V6J 1Z6
Office Phone: 604 660-6060
Fax: 604 775-4859
CONSENT FOR RELEASE OF INFORMATION AND ACKNOWLEDGEMENTS
I authorize the Ministry of Education to submit my information above to the Criminal Records Review Program ("CRRP") every 5 years
for as long as my information remains the same. I agree to provide a new signed Consent to a Criminal Record Check form if my
information or the requirements of the CRRP change. I understand that I may withdraw my consent at any time in the future and that
the Teacher Regulation Branch of the Ministry of Education will notify me when my information is submitted to the CRRP.
I have read and understand the Consent for Release of Information and Acknowledgements on the reverse. I hereby consent to the terms as indicated
by my signature below.
Signature:
Date Signed:
(yyyy/mm/dd)
Ministry of Education
Teacher Regulation Branch
Mailing Address:
Telephone: 604 660-6060
400-2025 West Broadway
Toll Free: 1 800 555-3684
Vancouver BC V6J 1Z6
Facsimile: 604 775-4859
Consent to a Criminal
Record Check
For working with children
and/or vulnerable adults
Schedule Type: B – APPLICANT TO/CERTIFICATE HOLDER WITH MINISTRY OF EDUCATION
Pursuant to the Criminal Records Review Act, all applicants to and certificate holders with the Ministry of Education must undergo a criminal
record check, which includes a vulnerable sector check, every five years. The Teacher Regulation Branch of the Ministry of Education
facilitates this requirement by collecting and submitting your consent to the Criminal Records Review Program of the Ministry of Public
Safety and Solicitor General who will perform the criminal record check.
IMPORTANT: Please complete this form using a dark ink pen, printing clearly and carefully. There may be a delay in processing
if the form is submitted incomplete or incorrectly, or if information cannot be read. When the form is completed and signed by you,
please forward it to the Teacher Regulation Branch by mail, or as a scanned email attachment (trb.certification@gov.bc.ca).
PART 1 – APPLICANT/CERTIFICATE HOLDER INFORMATION
File or Certificate Number:
Surname
Full First
Full Middle
Male
Female
Birth Date (YYYY/MM/DD)
Gender
Birth Place
(City, Province/State, Country)
OTHER NAMES USED OR HAVE USED: (e.g. alias, maiden name, birth name, or previous married name)
Other Surname(s)
Other First Name(s)
Other Middle Name(s)
1.
2.
3.
Mailing Address
City
Province
Country
Postal Code
BC Driver's Licence Number: DL
(Please leave blank if you don’t have a BC Driver’s Licence.)
Contact Phone
Email Address
PART 2 – ORGANIZATION INFORMATION – For Office Use Only
Regulatory Body Name: Teacher Regulation Branch, Ministry of Education
ID Number: 15/606188
Mailing Address: 400 – 2025 W Broadway
City: Vancouver
Province: BC
Country: Canada
Postal Code: V6J 1Z6
Office Phone: 604 660-6060
Fax: 604 775-4859
CONSENT FOR RELEASE OF INFORMATION AND ACKNOWLEDGEMENTS
I authorize the Ministry of Education to submit my information above to the Criminal Records Review Program ("CRRP") every 5 years
for as long as my information remains the same. I agree to provide a new signed Consent to a Criminal Record Check form if my
information or the requirements of the CRRP change. I understand that I may withdraw my consent at any time in the future and that
the Teacher Regulation Branch of the Ministry of Education will notify me when my information is submitted to the CRRP.
I have read and understand the Consent for Release of Information and Acknowledgements on the reverse. I hereby consent to the terms as indicated
by my signature below.
Signature:
Date Signed:
(yyyy/mm/dd)
Ministry of Education
Teacher Regulation Branch
Mailing Address:
Telephone: 604 660-6060
400-2025 West Broadway
Toll Free: 1 800 555-3684
Vancouver BC V6J 1Z6
Facsimile: 604 775-4859
Consent to a Criminal
Record Check
For working with children
and/or vulnerable adults
Page 2
CONSENT FOR RELEASE OF INFORMATION AND ACKNOWLEDGEMENTS
PURSUANT TO THE B.C. CRIMINAL RECORDS REVIEW ACT
I hereby consent to a check of criminal charges and convictions to determine whether I have a conviction or outstanding charge for
any relevant or specified offence(s) under the Criminal Records Review Act.
I hereby consent to a check of all available law enforcement systems, including any local police records.
I hereby consent to a Vulnerable Sector search to check if I have been convicted of and received a record suspension (formerly
known as a pardon) for any sexual offences as per the Criminal Records Review Act. For more information on Vulnerable Sector
searches, please visit the RCMP website.
I understand that as part of the Vulnerable Sector search, I may be required to submit fingerprints to confirm my identity.
I hereby authorize the release to the Deputy Registrar any documents in the custody of the police, the courts, corrections, and crown
counsel relating to any outstanding charges or convictions for any relevant or specified offence(s) as defined under the Criminal
Records Review Act or any police investigations, charges, or convictions deemed relevant by the Deputy Registrar.
Where the results of a check indicate that a criminal record or outstanding charge for a relevant or specified offence(s) may exist, I
agree to provide my fingerprints to verify any such criminal record.
My organization and I will be notified that I have an outstanding charge or conviction for a relevant or specified offence(s), and that
the matter has been referred to the Deputy Registrar for review.
The Deputy Registrar will determine whether or not I present a risk of physical or sexual abuse to children and/or physical, sexual,
or financial abuse to vulnerable adults as applicable; the determination will include consideration of any relevant or specified
offence(s) for which I have received a record suspension (formerly known as a pardon).
If I am charged with or convicted of any relevant or specified offence(s) at any time subsequent to the criminal record check
authorization herein, I further agree to report the charge(s) or conviction(s) to my organization and provide my organization, in a
timely manner, with a new signed Consent to a Criminal Record Check Form.
FREEDOM OF INFORMATION AND PROTECTION OF PRIVACY ACT (FOIPPA): The information requested on this form
is collected under the authority of the Criminal Records Review Act section 4(1) and section 26(c) of the Freedom of Information and
Protection of Privacy Act (FOIPPA). The information provided will be used to fulfil the requirements of the Criminal Records Review Act
for the release of criminal records information in accordance with the FOIPPA. If you have questions about the collection of your
personal information, please contact the Policy Analyst, Criminal Records Review Program, PO Box 9217 Stn Prov Govt, Victoria, BC
V8W 9J1 or by phone at 1 855 587-0185. Visit the Criminal Records Review Program online at:
www2.gov.bc.ca/gov/content/safety/crime-prevention/criminal-record-check.
January 2019 A
Ministry of Education
Teacher Regulation Branch
Mailing Address:
Telephone: 604 660-6060
400-2025 West Broadway
Toll Free: 1 800 555-3684
Vancouver BC V6J 1Z6
Facsimile: 604 775-4859
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