14.17.12
IHA MEMBER PROTECTION FORM
IHA Member Protection Declaration Form
Ice Hockey Australia has a duty of care to its members and to the general public who interact with its
employees, volunteers, members and others involved with Ice Hockey Australia activities. As part of
this duty of care and as a requirement of the Ice Hockey Australia’s Member Protection Policy, the
Ice Hockey Australia must enquire into the background of those applying for, undertaking or
remaining in any work (paid or voluntary) that involves working with people under the age of 18 years.
I ……………………………………………………….. of ………………………………………………………
(printed name)
(address)
.…………………………………………………………, born on the ……… / .…… / .……………….. is an
(dd)
(mm)
(year)
officer on:………………………………………… State Team as the team’s ………………………………
(State)
(position held)
and sincerely declare that:
1.
I do not have a national criminal record and/or convictions (including spent convictions) for:
a)
any sexual offence (including but not limited to, sexual assault, acts of indecency, child
pornography, child prostitution and carnal knowledge);
b)
any child-related personal violence offence;
c)
any assault, ill treatment or neglect of, or psychological harm to a child and any registrable
offence;
punishable by imprisonment for 12 months or more.
2.
I have not had any disciplinary proceedings brought against me by an employer, sporting
organisation or similar body involving child abuse, sexual misconduct or harassment, acts of
violence, intimidation or other forms of harassment.
3.
I have never been sanctioned for an anti-doping rule violation under any anti-doping policy
applicable to me.
4.
I have never participated in, facilitated or encouraged any practice prohibited by the World AntiDoping Agency Code or any other anti-doping policy applicable to me.
5.
To my knowledge there is no other matter that the Ice Hockey Australia may consider to
constitute a risk to its members, employees, volunteers, athletes or reputation by engaging me.
6.
I will notify the President’s of the organisation(s) engaging me immediately upon becoming
aware that any of the matters set out in clauses [1 to 6] above has changed for whatever
reason.
Declared in the State / Territory of …………………………………….…………………………………….
on ……... / ……. / ……….
Signature ……………………………………………………………..