Rockland Youth Basketball

2018-19 CORI Authorization Form

All volunteers age 18 or older working in Rockland Basketball must fill out the form below. No volunteers will be allowed to participate until a form has been submitted.

* LAST Name:

* FIRST Name:

Team(s) Coached:

* Birth Date:

* Email:

* ** Last 6 Digits of SS#** (6 Digits not 4):

Important: Please Make Sure You Enter the Last SIX digits of your SSN.

Rockland Youth Basketball is registered under the Youth Services provisions of M.G.L. c.6, § 172 to receive CORI for the purpose of screening current and otherwise qualified prospective volunteers.

As a prospective or current volunteer I understand that a CORI check will be submitted for my personal information to the DCJIS. I hereby acknowledge and provide permission to Rockland Youth Basketball to submit a CORI check for my information to the DCJIS. This authorization is valid for one year from the date of my acknowledgement. I may withdraw this authorization at any time by providing Rockland Youth Basketball with written notice of my intent to withdraw consent to a CORI check.

Rockland Youth Basketball may conduct subsequent CORI checks within one year of the date this Form was acknowledged by me, provided, however, that Rockland Youth Basketball, must first provide me with written notice of any subsequent check.

By checking the authorization below, I provide my consent to a CORI check and affirm that the information provided on this Authorization Form is true and accurate

Background Check Authorization *

* indicates required fields

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2018-19 CORI Authorization Form