Government of Ontario: Ministry of Community Safety and Correctional Services

Private Security and Investigative Services Branch

Consent and Release of Liability
Form Regarding Training

Please print or type in black ink

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Student Information

Last Name
First Name
Middle Name

Email Address

Date of Birth (yyyy/mm/dd)

I, (Print Student Name) consent to and authorize
(Print Name of Training Entity)

• 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 (Print 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 enure 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 personal information that you have provided in this form is collected under the authority of subsection 10(1) sub-paragraph (b)(iii) of the Private Security and Investigative Services Act, 2005 for the purpose of providing training to you in accordance with the Training and Testing Regulation made pursuant to the Act, and for the purpose of administering the licensing system authorized under the Act. For further information please contact a Customer Services Representative at 416 212-1650 or toll-free at 1 866 767-7454. 777 Bay Street, 3rd Floor, Toronto ON  M7A 2J6.

Name
Signature

Date (yyyy/mm/dd)