Framingham Public Schools
73 Mt. Wayte Avenue, Suite 5
Framingham, MA 01702
CRIMINAL OFFENDER RECORD INFORMATION (CORI) ACKNOWLEDGEMENT FORM
TO BE USED BY ORGANIZATIONS CONDUCTING CORI CHECKS FOR EMPLOYMENT, VOLUNTEER, SUBCONTRACTOR, LICENSING, AND HOUSING PURPOSES
Framingham Public Schools is registered under the provisions of M.G.L. c. 6, § 172 to receive CORI for the purpose of screening current and otherwise qualified prospective employees, subcontractors, volunteers, license applicants, current licensees, and applicants for the rental or lease of housing.
As a prospective or current employee, subcontractor, volunteer, license applicant, current licensee, 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 Framingham Public Schools 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 Framingham Public Schools with written notice of my intent to withdraw consent to a CORI check.
FOR EMPLOYMENT, VOLUNTEER, AND LICENSING PURPOSES ONLY: The Framingham Public Schools may conduct subsequent CORI checks within one year of the date this Form was signed by me provided, however, that Framingham Public Schools 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
REQUESTING LOCATION:______
Framingham Public Schools
73 Mt. Wayte Avenue, Suite 5
Framingham, MA 01702
SUBJECT INFORMATION:
______Last Name First Name Middle Name Suffix
______
Maiden Name (or other name(s) by which you have been known)
______
Date of Birth Place of Birth
Last Six Digits of Your Social Security Number :______
______Sex: ____ Height: ___ft. __in. Eye Color: ______Race: ______
Driver’s License or ID Number: ______State of Issue: ______
______
Mother’s Full Maiden Name Father’s Full Name
Current and Former Addresses: ______Street Number & Name City/Town State Zip
______StreetNumber & Name City/TownState Zip
______
StreetNumber & Name City/TownState Zip
The above information was verified by reviewing the following form(s) of government issued identification:
______
______
VERIFIED BY: ______
Name of Verifying Employee (Please Print)
Signature of Verifying Employee
Framingham Public Schools
BarbieriElementary School
100 Dudley Road
Framingham, Massachusetts01702
Telephone: 508-626-9187 Fax: 508-626-9176
Dr. Susan J. McGilvray-Rivet
This AGREEMENT is made between BarbieriElementary School and
(Name of the Visitor/Volunteer):______.
BarbieriElementary School is the owner of any information regarding students that may be of a confidential nature.
IT IS AGREED THAT:
1. The Visitor/Volunteer undertakes to keep any and all Information observed in Barbieri Elementary School regarding an identified student or any student in the observation setting, strictly confidential and not to disclose it to any person, firm, or individual without the express written consent of Barbieri Elementary School and or the parent/guardian of the identified student.
2. The visitor/volunteer shall not use information supplied by or obtained in BarbieriElementary School for any purpose other than to support the needs of the identified student.
3. The visitor/volunteer shall restrict dissemination all such information to those responsible employees whose knowledge of the same is necessary work with the identified student. In addition, the visitor/volunteer undertakes that employees, advisers, and consultants to whom such Information is disclosed are bound by the same commitment of confidentiality.
Signed for and on behalf of Barbieri Elementary School______Date______
Signed by the Visitor/Volunteer ______
Date______
CORI 5/12