Self-Declaration – Vulnerable Sector Check

Due to the nature of our work, it is the policy of the Company to have all new/prospective
volunteers, vendors and entertainers complete this self-declaration form. The Company is
committed to the protection of Residents & Team Members and, as such, has a duty to ensure
the suitability of any individual who works with a vulnerable population. To fulfill this obligation,
we ask that you complete and sign this form.

SELF-DECLARATION STATEMENT

I hereby declare that:

1. I have ☐ or have not ☐ been convicted of an offence under the Criminal Code, for which
no pardon has been granted.
2. I have ☐ or do not have ☐ outstanding charges against me.
3. I have ☐ or do not have ☐ clear history with afore mentioned aspects of Vulnerable Sector and
Criminal Record Checks.

I understand that misrepresentation may be grounds for termination of working relationship and I agree
to allow Amica Mature Lifestyles to perform a subsequent Vulnerable Sector Screening and Criminal
Record Check, if required.

Note: If you are presently charged with any offence pursuant to the Criminal Code and are subsequently
convicted, it is your responsibility to submit and report these changes immediately to the Life Enrichment
Coordinator or designate. If you have been convicted of an offence as described above please explain
using the space provided on the following form:

Date of Declaration: 05/15/2023

MM/DD/YYYY

Filipa Sousa
____________________________________
Volunteer/ Vendor/ Entertainer Printed Name

_____________________________________ 05/15/2023
__________________________
Volunteer/ Vendor/ Entertainer Signature MM/DD/YYYY

____________________________________
Witness Printed Name

____________________________________ ___________________________
Witness Signature MM/DD/YYYY

Please note a signed self-declaration of previous adult criminal convictions will not necessarily preclude
admission.

pg. 1/2
Notes

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___________________________
Volunteer/Vendor/ Entertainer Printed Name

___________________________ ___________________________
Volunteer/ Vendor/ Entertainer Signature Date

___________________________
Witness Printed Name

___________________________ ___________________________
Witness Signature Date

pg. 2/2