Billet Application for 2010 Student Leadership Conference at Carpenter High School

Please return competed application in a sealed envelope to Carpenter High School Attention: SLC Billet Committee.

Surname: ______________________________________ Date: _____________________

Box: ________ Town: ___________________ Street Address/Land Location: ________________________________

Adult Resident #1 Adult Resident #2

Name: ___________________________________
Maiden Name: ____________________________
Birth Date: _______________________________
Birthplace: _______________________________
Residence Phone #: ________________________
Work Phone # ____________________________
Cell Phone # ______________________________
Email: ___________________________________
Signature: ________________________________
Name: ___________________________________
Maiden Name: ____________________________
Birth Date: _______________________________
Birthplace: _______________________________
Residence Phone #: ________________________
Work Phone # ____________________________
Cell Phone # ______________________________
Email: ___________________________________
Signature: ________________________________

Please list all other residents of the home (children, boarders, relatives, etc.).
Full Name M/F Date of Birth Birthplace School Attending

Number of billets: _________ (must be at least 2) Billet gender preference: Male ____ Female ____
Do you have any of the following in or around your residence: Smokers ______ Dogs _____ Cats _____
#1 Statement of Consent
I hereby consent to a Criminal Record Check registered in my name and the National Repository for Criminal Records in Canada.
Pursuant to Section 8(1) of the Privacy Act of Canada, I hereby authorize the Royal Canadian Mounted police to disclose my
personal information to the SLC 2010 CHS School Committee, Meadow Lake, Saskatchewan.
#2 Consent for Persons Applying for Positions Within the Vulnerable Sector
I consent to a search being made in the automated criminal records retrieval system maintained by the Royal Canadian Mounted
police to find out if I have been convicted of, and been granted a pardon for, any of the sexual offences that are listed in the
schedule to the Criminal Records Act.
I understand that, as a result of giving this consent, if I am suspected of being the person named in a criminal record for one of the
sexual offences listed in the schedule to the Criminal Records Act in respect of which a pardon was granted or issued, that record
may be proved by the Commissioner of the Royal Canadian Mounted Police to the Minister of Public Safety and Emergency
Preparedness Canada, who may then disclose all or part of the information contained in that record to a police force or other
authorized body. That police force or authorized body will then disclose that information to me. If I further consent in writing to
disclosure of that information to the person or organization referred to above that requested the verification, that information will
be disclosed to that person or organization.

Signature Adult Resident #1________________________ Signature Adult Resident #2 _________________________

For Office Use Only

A name check, based on the information supplied, of the police records reveals:
1) No Criminal Record – includes Vulnerable Sector Check ____
2) May or may not have a criminal record, which can only be verified thru fingerprint examination _____

Dated: ________________
Signature, Name and Position _________________________________________ Police Department ______________
For SLC Committee use only: Accepted ____ Rejected _____
Location of Residence: Meadow Lake _______ RM of Meadow Lake ______ Other _________________________