Consent and Release of Liability Form Regarding Training



Student Information


Important: You must provide your full legal name, as it appears on the identification you are carrying with you to the test venue on the test day

Last Name

First Name

Middle Name (s)

Other Name(s) (Maiden name, former name, etc. - please specify) (s)

Unit No

Street No

Street Name

PO Box

City / Town

Province

Postal Code

Business Telephone No.

Fax No.

Email Address


Mailing Address (Only complete if different from the address noted above)


Unit No

Street No

Street Name

PO Box

City / Town

Province

Postal Code

Date of Birth

Gender

Male     Female


• to collect personal information from or about me for the purpose of providing training in accordance with the Training and Testing Regulation made under the Private Security and Investigative Services Act, 2005 (“PSISA”);

• to disclose personal information collected from or about me, including whether or not I have successfully completed the required training under the Training and Testing Regulation, to the Private Security and Investigative Services Branch of the Ministry of Community Safety and Correctional Services for the purpose of determining whether I am eligible to be licensed as a security guard or private investigator, and for the purpose of administering the licensing system authorized under the PSISA; and I also consent to and authorize the Private Security and Investigative Services Branch of the Ministry of Community Safety and Correctional Services to disclose personal information collected about me, for the purpose of advising the Ministry’s Test Delivery Vendor as to whether or not I have completed the training required under the Training and Testing Regulation; and I hereby release and discharge Her Majesty the Queen in Right of Ontario, the

Name of Training Entity

and their respective directors, employees, subcontractors, volunteers, servants and agents, including their successors and assigns, from any and all actions, claims and demands for damages, loss or injury, howsoever arising, except as a result of negligence or wilful misconduct which may hereafter be sustained by myself as a result of the collection, use and disclosure of personal information as authorized by this form. This Release of Liability shall be binding upon and shall ensure to the benefit of my respective heirs, and administrators. I certify that I have read the information in this form thoroughly, that I fully understand it, and that by signing below, I have the capacity to provide consent, and that I am providing consent freely and voluntarily


The information provided is collected under the authority of Section 11 of the Private Security and Investigative Services Act, 2005 for the purpose of issuing a licence under the Act. If you have any questions, call a ServiceOntario Customer Service Representative toll-free at 1-866- 767-7454 (Canada). TTY users call us toll-free at 1-800-268-7095 (TTY Canada). Or mail, Private Security and Investigative Services Branch, 25 Grosvenor Street, 12th Floor, Toronto ON M7A 1Y6

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