Williamstown Cal Ripken - LeagueAthletics.com
Williamstown Cal Ripken “A safe place to dream and succeed”
P.O. Box 54
Williamstown, MA 01267
Criminal Offender Record Information Acknowledgement Form Williamstown Cal Ripken is registered under the provisions of M.G.L. c. 6, § 172 to receive CORI for the purposes of screening current and otherwise qualified prospective volunteers. As a volunteer, I understand that a CORI check will be submitted for my personal information to the Department of Criminal Justice Information Services (DCJIS). I hereby acknowledge and provide permission to Williamstown Cal Ripken to submit a CORI check for my information to the DCJIS. This authorization is valid for one year from the date of my signature. I may withdraw this authorization at any time by providing Williamstown Cal Ripken with written notice of my intent to withdraw consent to a CORI check. Williamstown Cal Ripken may conduct subsequent CORI checks within one year of the date this Form was sign by me provided however, that Williamstown Cal Ripken must first provide me with written notice of this check. By signing below, I provide my consent to a CORI check and acknowledge that the information provided on Page 2 of this Acknowledgement Form is true and accurate.
_____________________________ Signature
______________________ Date
1
Williamstown Cal Ripken “A safe place to dream and succeed”
P.O. Box 54
Williamstown, MA 01267
Applicant's Information An asterisk (*) denotes a required field Program you are volunteering for (please check): Manager ___ Coach ___ Assistant Coach ___ Other ____ Last name: __________________ First name*: ______________M.I. ___ Suffix _____ Maiden name (if applicable): ________________________ Place of Birth:________________________ Date of Birth: _____________ Social Security Number*:____________-_________-_________ Sex:____
Height:____ft. ____in.
Eye Color:______ Race:_______
Driver’s License or ID Number:____________
State of Issue:_____________
Current and Former Addresses: _____________________________________________________________ Street Number & Name City/Town State Zip _____________________________________________________________ Street Number & Name City/Town State Zip _____________________________________________________________ The above information was verified by reviewing the following form(s) of government issued identification: ___________________________________________ ___________________________________________ Verified by: ________________________ Name ________________________ Signature
***You MUST send a copy of your driver's license OR passport when submitting the CORI form.*** 2
P.O. Box 54
Williamstown, MA 01267
Criminal Offender Record Information Acknowledgement Form Williamstown Cal Ripken is registered under the provisions of M.G.L. c. 6, § 172 to receive CORI for the purposes of screening current and otherwise qualified prospective volunteers. As a volunteer, I understand that a CORI check will be submitted for my personal information to the Department of Criminal Justice Information Services (DCJIS). I hereby acknowledge and provide permission to Williamstown Cal Ripken to submit a CORI check for my information to the DCJIS. This authorization is valid for one year from the date of my signature. I may withdraw this authorization at any time by providing Williamstown Cal Ripken with written notice of my intent to withdraw consent to a CORI check. Williamstown Cal Ripken may conduct subsequent CORI checks within one year of the date this Form was sign by me provided however, that Williamstown Cal Ripken must first provide me with written notice of this check. By signing below, I provide my consent to a CORI check and acknowledge that the information provided on Page 2 of this Acknowledgement Form is true and accurate.
_____________________________ Signature
______________________ Date
1
Williamstown Cal Ripken “A safe place to dream and succeed”
P.O. Box 54
Williamstown, MA 01267
Applicant's Information An asterisk (*) denotes a required field Program you are volunteering for (please check): Manager ___ Coach ___ Assistant Coach ___ Other ____ Last name: __________________ First name*: ______________M.I. ___ Suffix _____ Maiden name (if applicable): ________________________ Place of Birth:________________________ Date of Birth: _____________ Social Security Number*:____________-_________-_________ Sex:____
Height:____ft. ____in.
Eye Color:______ Race:_______
Driver’s License or ID Number:____________
State of Issue:_____________
Current and Former Addresses: _____________________________________________________________ Street Number & Name City/Town State Zip _____________________________________________________________ Street Number & Name City/Town State Zip _____________________________________________________________ The above information was verified by reviewing the following form(s) of government issued identification: ___________________________________________ ___________________________________________ Verified by: ________________________ Name ________________________ Signature
***You MUST send a copy of your driver's license OR passport when submitting the CORI form.*** 2
