Fillable Volunteer Screening Checklist - Scouts Canada printable pdf download

Volunteer Screening Checklist

Contents of this form are confidential. The Group Commissioner / Group Registrar must enter this information in

myscouts.ca. DO NOT COPY

First Name :

Candidate Information:

Last Name:

Date of Birth (mm/dd/yyyy):

Member Number:

Scouting Group Name and Section:

Screening Interview-Confidential Interview to be completed by two Scouts Canada approved interviewers. This section to be completed following the

interview, not in the presence of the candidate.

Yes

Uncertain

Commits to appropriate adult volunteer/participant interaction:

Comments:

Yes

Uncertain

Commits to providing challenging programs:

Comments:

Yes

Uncertain

Commits to active expression of the Mission, Principles and Promise :

Comments:

Yes

Uncertain

Commits to outdoor programming :

Comments:

Yes

Uncertain

Commits to personal development :

Comments:

Yes

Uncertain

Commits to be a positive role model :

Comments:

Yes

Uncertain

Commits to being open, honest and objective :

Comments:

Yes

Uncertain

Commits to Shared Leadership Approach :

Comments:

Yes

Uncertain

Commits to child protection and safe programming :

Comments:

Interviewed By:

1st Interviewer Name:

Scouting Role:

Date (mm/dd/yyyy):

2nd Interviewer Name:

Scouting Role:

Date (mm/dd/yyyy):

Yes

Is the Candidate acceptable for volunteer service under the guidelines?

Comments:

Reference Checks-each reference must be contacted and checked

Reference Notes:

Answer with Yes, No, or Uncertain Where Indicated By

Would the

How long

Willing to have

Candidate

reference

has

Status of

the applicant

Contact Date

works well

Reference

Reference Name:

Contacted by:

recommend

Relationship to applicant

reference

work one-on-

(mm/dd/yyyy)

with adults?

with youth?

Check

the

known the

one with own

child?*

candidate?*

candidate?

Comments to explain No and Uncertain Responses:

Ref. Name:

Ref. Email :

Ref. Home Ph. #:

Ref. Alt. Ph. #:

Ref. Name:

Ref. Email :

Ref. Home Ph. #:

Ref. Alt. Ph. #:

Ref. Name:

Ref. Email :

Ref. Home Ph. #:

Ref. Alt. Ph. #:

Commissioner Approval (Council, Area or Group)

I confirm that the above named person has been fully screened as per Scouts Canada's Adult Volunteer Screening Procedure and is acceptable to work with youth as an adult

volunteer member.

Date (mm/dd/yyyy):

Signed:___________________________________________________________

Council Executive Director

I confirm that the Adult Volunteer Screening Procedure has been completed for the above named person, that a clean Police Record Check is on file and this applicant is

acceptable for membership with Scouts Canada.

Date (mm/dd/yyyy):

Signed:___________________________________________________________

Volunteer Screening Checklist March 2013

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