Correctional Service Service correctionnel

Canada Canada
PROTECTED B ONCE COMPLETED

NOTE: Reference document CD559

PERSONAL INFORMATION BANK

VISITING APPLICATION PUT AWAY ON FILE ► Offender VC file

Family name (name of

NOTE: Shaded areas are for office use only inmate you wish to visit) ►

CPIC CHECK COMPLETED Yes No

Given name(s) ►
FPS Number ►
Date of Birth ►
Institution Region

Completing Operational Unit

IMPORTANT
PLEASE READ THIS FORM CAREFULLY AS FAILURE TO COMPLETE THIS FORM COULD RESULT IN DELAYS OF APPROVAL PROCESS. Answer
all questions and sign in the applicable spaces. You are required to submit TWO current photographs of yourself that contain a view of your full face, head
and shoulders only (minimum size: 5cmX 3.5cm / 2’’x 1½’’). You are also required to submit a PHOTOCOPY of TWO current government issued ID’s, at least
one of those must be photo ID (i.e. Driver’s Licence, Health card, etc.) YOU WILL NEED TO PROVIDE THAT ID WHEN YOU COME FOR THE VISIT. Lastly,
you must complete the Institutional Access CPIC Clearance Request Form in order to request access to the institution. This form is located on the same page
that the visiting application is located. All applications must be submitted by mail, addressed to the Visits and Correspondence unit of the institution
you wish to visit. No fax or scan copy will be accepted.
http://www.csc-scc.gc.ca/etablissements/001002-0001-eng.shtml
NOTE: Failure to complete the form fully will result in delays in the visitor approval process. Providing false information is sufficient to deny
access.
PRIVACY ACT STATEMENT
Personal information about you is collected under the authority of the Corrections and Conditional Release Act to review your suitability for visiting privileges
at the CSC. This information is collected, with no obligation on your part, and held in the Visits and Correspondence Bank; however, your refusal to comply
would result in the denial of visiting privileges. This information cannot be disclosed to other persons without your consent EXCEPT where disclosure would
be justified pursuant to one of the paragraphs of subsection 8(2) of the Privacy Act.
INFORMATION ON APPLICANT
Your name Your date of birth Your place of birth
Maiden name
Family name Given names (in full) (if applicable) YYYY-MM-DD City/Town Province/Country

Civic Address Apt. no. City Province Postal code

No. Street

Is the mailing address the same as the

civic address?
Yes No ► If no, provide mailing address:
Telephone no. where a CSC representative Motor vehicle
Your telephone no. Your physical description
could contact you if necessary licence no.
Colour of Colour of
Home Height Weight At work OR Other than home phone
hair eyes
( ) - ( ) - ( ) -
I am the inmate's
Father Mother Spouse Common-law partner Brother

Sister Son Daughter I am a victim of an offence committed by this offender

Other (volunteer, friend, cousin, aunt, uncle) (specify type and length of relationship): ►
Explain if extenuating circumstances:

Name of person and his/her telephone no. where a CSC ( ) -

representative may contact in an emergency
Name (print) Telephone no.
Are you on another inmate's visiting list? Are you a volunteer visitor at this or any other institution?
No Yes No Yes
If YES, state inmate's name, your relationship to him/her and which If YES, state the name of the group or program you take part in and the
institution he/she is in. institution's name.
► ►
CSC/SCC 0653E (R-2018-11) (Word Version) Information may be accessible or protected as required under the DISTRIBUTION
(Voir CSC/SCC 0653F pour la version française) Page 1 of 3 provisions of the Access to Information Act and the Privacy Act. Original = Offender VC file
Copy= Security Intelligent Officer
 For Office Use Only
Name FPS No.

Give the first and last names and date of birth of any of your children (under
the provincial age of majority, see CD 559 Visits, Annex B) for whom you
Are there at present any outstanding charges against you?
wish visiting privileges (see also section 3 of Acknowledgement and Consent
on page 3).
First and Last name(s) (print) Date of Birth Yes No
(YYYY-MM-DD)
Have you ever been convicted of a criminal offence for which you have not
been granted a pardon, or an offence for which you have been granted a
pardon and such a pardon has been revoked?

Yes No

Please indicate what document you will be using as identification when

visiting the institution. A photocopy of this ID must be provided along with ►
this application.

Date received (YYYY-MM-DD) and Date application

Comments
by whom (print) reviewed (YYYY-MM-DD)
Approved

Denied

CORRECTIONS AND CONDITIONAL RELEASE ACT (Excerpts)

45. Every person commits a summary conviction offence who:
a) is in possession of contraband beyond the visitor control point in a penitentiary;
b) is in possession of anything referred to in paragraph (b) or (c) of the definition “contraband” in section 2 before the visitor control point at a
penitentiary;
c) delivers contraband to, or receives contraband from, an inmate;
d) without prior authorization, delivers jewellery to, or receives jewellery from, an inmate; or
e) trespasses at a penitentiary.

“Contraband” means:
a) an intoxicant,
b) a weapon or a component thereof, ammunition for a weapon, and anything that is designed to kill, injure or disable a person or that is altered
so as to be capable of killing, injuring or disabling a person, when possessed without prior authorization,
c) an explosive or a bomb or a component thereof,
d) currency over any applicable prescribed limit, when possessed without prior authorization, and
e) any item not described in paragraphs (a) to (d) that could jeopardize the security of a penitentiary or the safety of persons, when that item is
possessed without prior authorization.

60. (1) A staff member may conduct a frisk search of a visitor where the staff member suspects on reasonable grounds that the visitor is carrying
contraband or carrying other evidence relating to an offence under section 45.

(2) Where a staff member

(a) suspects, on reasonable grounds that a visitor is carrying contraband or carrying other evidence relating to an offence under section 45, and
believes that a strip search is necessary to find the contraband or evidence, and
(b) satisfies the institutional head that there are reasonable grounds
(i) to suspect that the visitor is carrying contraband or carrying other evidence relating to an offence under section 45, and
(ii) to believe that a strip search is necessary to find the contraband or evidence, a staff member of the same sex as the visitor may, after
giving the visitor the option of voluntarily leaving the penitentiary forthwith, conduct a strip search of the visitor.

CSC/SCC 0653E (R-2018-11) (Word Version)

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 For Office Use Only
Name FPS No.

(3) Where a staff member believes on reasonable grounds that a visitor is carrying contraband or carrying other evidence relating to an offence
under section 45 and that a strip search is necessary to find the contraband or evidence,
(a) the staff member may detain the visitor in order to
(i) obtain the authorization of the institutional head to conduct a strip search, or
(ii) obtain the services of the police; and
(b) where the staff member satisfies the institutional head that there are reasonable grounds to believe
(i) that the visitor is carrying contraband or carrying other evidence relating to an offence under section 45, and
(ii) that a strip search is necessary to find the contraband or evidence, the institutional head may authorize a staff member of the same sex
as the visitor to conduct a strip search of the visitor.

(4) A visitor who is detained pursuant to subsection (3) shall

(a) be informed promptly of the reasons for the detention; and
(b) before being searched, be given a reasonable opportunity to retain and instruct counsel without delay and be informed of that right.

Searches of Visitors
54. (1) A staff member may conduct a routine non-intrusive search or a routine frisk search of a visitor, without individualized suspicion, where the visitor is
entering or leaving the penitentiary.
(2) If a visitor refuses to undergo a search referred to in subsection (1), the institutional head or a staff member designated by the institutional head
may
(a) prohibit a contact visit with an inmate and authorize a non-contact visit; or
(b) require the visitor to leave the penitentiary forthwith.

ACKNOWLEDGMENT AND CONSENT

1. I understand that the Correctional Service of Canada has the sole right to determine my suitability as an inmate’s visitor. I further understand that
approval of visiting privileges is conditional upon satisfactory results of a criminal record name check and I hereby give my consent to the Correctional
Service of Canada to use the information provided on this form to conduct such a check. To this end, I certify that the information I have submitted is
true and accurate to the best of my knowledge, and I agree to notify institutional authorities immediately should there be any changes to that information.
I also give my consent that criminal record name checks be conducted every two years as per CD 559, provided that I continue to participate in visits. I
acknowledge that the submission of false or misleading information or the failure to advise of changes may result in denial or suspension of my visiting
privileges for an indefinite period. Finally, I agree to observe all stated rules, regulations and policies while visiting this institution and understand that the
failure to do so may likewise result in suspension of my visiting privileges for an indefinite period.

2. I understand that before each visit, I could be subjected to a search as per CCRA and CCRR. Furthermore, I understand that if I refuse to be searched, I
may be denied access to the institution or that a contact visit may be replaced with a non-contact visit.

3. I understand that my oral, visual or telecommunications with an inmate may be subject to interception.

►
Name (Print) Signature of applicant Date (YYYY-MM-DD)

For visitors who wish visiting privileges for their children or wards
4. a) In consideration of my child or ward being granted visiting privileges, I consent to a search of his/her person by a walk-through scanner or hand-
held scanning device, and to a search of his/her personal property, in accordance with the procedure outlined in section 60.
b) I understand that the institution may consider it necessary that my child or ward be subjected to searches as per CD 566-8 Searching of Staff and
Visitors and for this purpose.

I hereby consent to such searches being performed.

OR
I wish to be contacted for my consent prior to such searches being performed.

Furthermore, I require do not require That I or another accompanying adult be present when such searches take place.

►
Name (print) Signature of parent or legal guardian Date (YYYY-MM-DD)

CSC/SCC 0653E (R-2018-11) (Word Version)

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