SOUTH SHORE CONGREGATIONAL YOUTH CONFERENCE

"A Vacation with a Purpose"

CRIMINAL OFFENDER RECORD INFORMATION (CORI)

ACKNOWLEDGEMENT FORM

SSCYC, Inc. 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 employees, subcontractors, volunteers, license applicants, current licenses, and applicants for the rental or lease of housing.

As a prospective or current employee, subcontractor, volunteer, license applicant, current license, or applicant for the rental or lease of housing, I understand that a CORI check will be submitted for my personal information to the DCJIS. I hereby acknowledge and provide permission to SSCYC, Inc. 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 SSCYC, Inc. written notice of my intent to withdraw consent to a CORI Check.

FOR EMPLOYMENT, VOLUNTEER, AND LICENSING PURPOSES ONLY: the SSCYC, Inc. may conduct subsequent CORI checks within one (1) year of the date this form was signed by me, provided, however, that SSCYC, Inc. must first provide me with written notice of this check.

PERSONAL INFORMATION

M F



How long have you lived at this address?

If you have lived at your current address for less than 5 years


How long did you live at this address?









Height







The completed CORI Acknowledgement form will be sent to you by email (above address).
Please make a copy of both sides of your driver's license and send in with the form.
You must print this form out, sign it, and send it to:

SSCYC, INC.
Attn: Staff Applications
P.O. Box 890008
Weymouth, MA 02189-0001