Risk Manager - CORI Submitter Agreement Form - Massachusetts Youth Soccer Individual Agreement of Non‐Disclosure

Does your organization have more than one Risk Manager/CORI Submitter?
Please select any other roles you have within your organization in addition to Risk Manager/CORI Submitter

Although you will not be viewing the adult's Criminal Offender Record Information (CORI) report, you are responsible for verification of your adult members personal information that is submitted for processing their CORI background check.

By signing below, I acknowledge that I have read and understand the provisions of Massachusetts General Laws, c. 6, §§ 167‐178B, of which sections 177‐178 provide that it is a criminal offense to knowingly disclose to any unauthorized person or agency any criminal offender record information concerning an individual or to knowingly falsify any criminal offender record information. Unauthorized access to or dissemination of criminal offender record information is punishable by a fine of not more than five thousand dollars ($5,000.00), or imprisonment in jail or house of correction for not more than one year, or both. Any such dissemination also subjects me to a suit for civil damages and/or a civil fine of up to five thousand dollars ($5,000.00) for each such knowing violation. I also understand that a criminal record check will be conducted on me by the Criminal Justice Agency and/or the Department of Criminal Justice Information Services as a prerequisite to my having authorization for access to CORI.

This document is to be completed by ALL persons employed by, contracted with, or otherwise operating in association with the herein named agency, and who may have access to CORI. MASSACHUSETTS GENERAL LAWS Chapter 6 Section 177 Any aggrieved person may institute a civil action in superior court for damages or to restrain any violation of sections one hundred and sixty‐eight to one hundred and seventy‐five, inclusive. If it is found in any such action that there has occurred a willful violation, the violator shall not be entitled to claim any privilege absolute or qualified, and he shall in addition to any liability for such actual damages as may be shown, be liable for exemplary damages of not less than one hundred and not more than one thousand dollars for each violation, together with costs and reasonable attorneys’ fees and disbursements incurred by the person bringing the action. Section 178 An individual or entity who knowingly requests, obtains or attempts to obtain criminal offender record information or a self‐audit from the department under false pretenses, knowingly communicates or attempts to communicate criminal offender record information to any other individual or entity except in accordance with the provisions of sections 168 through 175, or knowingly falsifies criminal offender record information, or any records relating thereto, or who requests or requires a person to provide a copy of his or her criminal offender record information except as authorized pursuant to section 172, shall for each offense be punished by imprisonment in a jail or house of correction for not more than 1 year or by a fine of not more than $5,000 or by both such fine and imprisonment, and in the case of an entity that is not a natural person, the amount of the fine may not be more than $50,000 for each violation. An individual or entity who knowingly requests, obtains or attempts to obtain juvenile delinquency records from the department under false pretenses, knowingly communicates or seeks to communicate juvenile criminal records to any other individual or entity except in accordance with the provisions of sections 168 through 175, or knowingly falsifies juvenile criminal records, shall for each offense be punished by imprisonment in a jail or house of correction for not more than 1 year or by a fine of not more than $7,500, or by both such fine and imprisonment, and in the case of an entity that is not a natural person, the amount of the fine may not be more than $75,000 for each violation. This section shall not apply to, and no prosecution shall be brought against, a law enforcement officer who, in good faith, obtains or seeks to obtain or communicates or seeks to communicate criminal offender record information in the furtherance of his or her official duties. By electronically signing below, I am in agreement with all requirements and provide my consent to a CORI check and affirm that the information provided on this Agreement Form is true and accurate.



Use the box below to provide your electronic signature. * 🛈
clear

Once online form is completed, please email CORI@mayouthsoccer.org providing several days and time you are available to meet via teleconferencing to complete the CORI Verification process (Commonwealth of Mass law).  Mass Youth Soccer will reply to your email with a meeting link.