Volunteer Registration Form

This Form Must Be Completed by the Applicant

Complete and submit the form. A copy will be emailed to PCR staff and to the email address that you enter below.

Personal Information

First name:	Last name:

Address 1:	Address 2:

City:	State:	Zip:

Phone:	Phone 2:	Email:

Education

Current Educational Institution:

Anticipated Date of Graduation :

Junior/Senior High School:

Please select highest grade completed)

7 8 9 10 11 12

Undergraduate/Graduate
Degree & Major:

Graduation Year:

Experience:

Please list previous volunteer and/or employment experience. Indicate if you have
had experience with persons with developmental disabilities.

What motivated you to volunteer with PCR?

References

Name	Daytime Phone	Night Phone

Photo Release:

May PCR use your photographic likeness for publicity purposes?

Yes No

Disclosure:

I hereby declare or affirm under penalty of perjury that I
have not been convicted of, nor am I the subject of
pending charges for the commission or attempt to commit
or assault with intent to commit murder, child abuse, rape,
child pornography, child abduction, kidnapping of a child,
manufacturing, distributing, or dispensing a controlled
dangerous substance, or hiring, soliciting, engaging, or
using a minor for the purpose of manufacturing,
distributing, or delivering a controlled substance or sexual
offense, defined under Article 27, Subsection 464, 464A,
464B, and 464C of the Annotated Code of Maryland or
an equivalent offense and I certify I am the applicant
whose information is listed above.

Yes No

Date:

Coming together, creating community.

This Form Must Be Completed by the Applicant