Form Csc/scc 0653-01e - Visiting Application Child Safety Waiver printable pdf download

Correctional Service

Service correctionnel

PROTECTED

ONCE COMPLETED

Canada

NOTE: Reference document

CD 559

and

CD 710-8

PERSONAL INFORMATION BANK

►

PUT AWAY ON FILE

Original = Offender VC file

VISITING APPLICATION –

►

FPS Number

CHILD SAFETY WAIVER

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

THIS FORM IS TO BE FILLED IN CONJUNCTION WITH FORM CSC 0653E, VISITING APPLICATION

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.

parent or accompanying adult of the following child/children, absolve the

Correctional Service of Canada from any responsibility it may have in allowing the said child/children to accompany me on a visit to the

CSC Institution/facility.

For greater certainty, but not so as to restrict the generality of the foregoing terms, I exonerate the Correctional Service of Canada or its

servants for any responsibility resulting from an injury sustained by the said child/children while on federal property. I also waive my rights

to any claims or actions which I may have against the Correctional Service of Canada or its servants resulting from the admission of the

said child/children in a federal institution. Finally, I acknowledge that I am responsible for the following child/children at all times while

he/she is in the institution.

Name of the above-mentioned child/children

AGE

►

Signature of the above-mentioned parent or

Date

(YYYY-MM-DD)

accompanying adult

►

Witnessing Officer’s Name

Signature

Date

(Print)

(YYYY-MM-DD)

CSC/SCC 0653-01E (R-2015-07) (PDF )

Information may be accessible or protected as required under

DISTRIBUTION

(Voir CSC/SCC 0653-1F pour la version française)

the provisions of the Access to Information Act and the Privacy

Act.

Copy = Security Intelligent Officer

Form Csc/scc 0653-01e - Visiting Application Child Safety Waiver

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