CORI/KIDSAFE FORM

The Criminal Offender Record Information (CORI) Support Services Unit provides CORI to Board Certified, non-criminal justice agencies such as schools, day care centers, and municipal government agencies.  Massachusetts Youth Soccer Association has been certified for access to all existing CORI information including pending cases, convictions, and non-conviction criminal case data.  Massachusetts Youth Soccer is prohibited from disseminating this information for any purpose other than to further the safety and protection of children.  This information will be maintained in strict accordance with the laws of the Commonwealth.

Please fill out the information below completely, precisely and exactly.  DO NOT use any abbreviations.

Volunteer Application and Disclosure Statement


I understand that my volunteer position is contingent upon the following:

1. Review and approval of a truthfully completed and signed application and disclosure statement.

2. Receipt of a report declaring non-evidence of criminal history from the Commonwealth of Massachusetts.

I may be disqualified from volunteering due to any misrepresentations or omissions on the Application/Disclosure Statement.

The Kid Safe program instituted by the National Risk Management Committee mandates that volunteers be screened and a background check performed prior to being accepted as a volunteer and every 3 years thereafter as long as the volunteer is active in youth sports.

Please note all sensitive information is encrypted and stored on a secure server.

INDIVIDUAL FILING
RESIDENTIAL ADDRESS
CONTACT INFORMATION

Have you ever been:
You will be requested to complete a REQUEST FOR CRIMINAL HISTORY authorization by the Kidsafe Policy .  The request will permit Massachusetts Youth Soccer Association to obtain a report of your criminal convictions, disciplinary board final decisions and subsequent criminal charges associated with the conduct that is the subject of the disciplinary board final decision, and the record of civil adjudications pertain to offenses against children.  Massachusetts Youth Soccer will use the report only for the purposes of making its decision whether to permit you to act as a volunteer and for no other purpose.

I DECLARE UNDER PENALTY OF PERJURY UNDER THE COMMONWEALTH OF MASSACHUSETTS THAT THE FOREGOING IS TRUE AND CORRECT.
CRIMES AGAINST PERSONS
Murder, Kidnapping Assault, Assault of a child, Custodial assault, Harassment, Stalking, Reckless endangerment, Coercion, Rape, Rape of A child, Robbery, First degree burglary, Residential burglary, Manslaughter, Extortion, Indecent liberties, Incest, Vehicular homicide, Vehicular assault, promoting prostitution, communicating with a minor for unlawful purposes, unlawful imprisonment, sexual exploitation of minors, criminal mistreatment, child abuse or neglect, custodial interference, child molestation, sexual misconduct with a minor, patronizing a juvenile prostitute, child abandonment, promoting pornography, selling or distributing erotic material to a minor, violation of child abuse restraining order, child buying or selling, prostitution, felony indecent exposure, etc.

CRIMES AGAINST PROPERTY
Theft of money, auto theft, fraud, perjury, second-degree burglary, vehicle prowling, possession of stolen property, criminal trespass, arson, etc.
* Indicates Response Required