CORI Authorization Form by NikFozzar

VIEWS: 205 PAGES: 1

									                                       BARNSTABLE COUNTY 4-H PROGRAM
                                              CORI Request Form

I understand that by submitting this form, I agree that Barnstable County Youth & Family Programs may request all
available criminal offender record information (CORI) on myself pursuant to Chapter 6, Section 172H, mandating
organizations engaged in providing activities or programs to children 18 years of age of less that accepts volunteers,
obtain CORI checks regarding all volunteers prior to accepting any person as a volunteer or allowing them to continue in
a volunteer capacity with the organization. I attest that any additional adult family members age 18 or over, or any
unrelated adults living in my household, have also read this agreement and are also willing to have a CORI check
conducted on them by Barnstable County, as indicated by their information and signatures below.*
Volunteer Information: (Please Print)
______________________________               ______________________              _________________
Last Name                                    First Name                          Middle Name
_________________________                                               Copy of Photo ID attached?:
Maiden Name or Alias (if Applicable)                                      (required – will be kept in a secure file)

4-H Local Office:          BARNSTABLE

Date of Birth: __________________ Social Security Number: __________ - __________ - __________
                                             (Requested but not required)

Home & Mailing Address: _______________________________________________ _________________________

City, State, & Zip Code: _______________________________________________________                                         ___

Telephone: _____________________________________ E-Mail: ______________                                ________________

Signature of Volunteer: _____________________________________ Date: _________________________


*In the case of home-based clubs or volunteer activities, please list any additional adults, age 18 years or over, related or unrelated,
living in the house where the youth activities will occur who will come into contact with youth. Please provide names, aliases,
birthdates, and signatures for all such adults below: (Please use the back of this form if more space is required and enter all
information required below). Copies of photo IDs must be on file.
Signature of any related/unrelated adults living in the above volunteer’s household, authorizing CORI checks:

Additional Adult #1:
___________________________ ____________________ ____________                             ________________________
Last Name                    First Name           Middle Name                              Maiden Name/Aliases
Date of Birth: ________________________        Social Security Number (Optional): ___________-___________-____________
Signature of other related/unrelated adults in household: ___________________________________________________
( ) Check if you want to apply to become a 4-H Volunteer              Copy of Photo ID:
( ) Check if you have already completed the 4-H screening process (application & references)

Additional Adult #2:
___________________________ ____________________ ____________                             ________________________
Last Name                    First Name           Middle Name                              Maiden Name/Aliases
Date of Birth: ________________________        Social Security Number (Optional): ___________-___________-____________
Signature of other related/unrelated adults in household: ___________________________________________________
( ) Check if you want to apply to become a 4-H Volunteer              Copy of Photo ID:
( ) Check if you have already completed the 4-H screening process (application & references)

            Return to: CC Cooperative Extension, P.O. Box 367, Barnstable, MA 02630 Attention: Judy Vollmer

								
To top