2. 1. I am requesting to be a Companion for the following Participant:
4. Participant Name*

   First, Middle Initial, Last

5. Phone Number*
9. 2. Activity Information:
11. Activity Name*
12. Start Date
    Start Date
13. End Date
    End Date
15. Activity Location/Facility Name
19. 3. Disability Agency Representative*

    1. YES (List up to 3 staff in section 3a)
    2. NO (skip to number 4)
21. Agency Name
23. Staff Member Completing Form
24. Title/Position
26. Agency Address
28. City
29. State
30. Zip Code
32. Phone Number
33. E-mail
37. 3a.
39. Staff Name

    First, Middle Initial, Last

40. Age
42. Phone Number
43. E-Mail
45. Emergency Contact/Relationship/Phone Number

    *In the event of any emergency while in our facilities, who should be contacted other than the Agency Representative.

49. Staff Name

    First, Middle Initial, Last

50. Age
52. Phone Number
53. E-Mail
55. Emergency Contact/Relationship/Phone Number

    *In the event of any emergency while in our facilities, who should be contacted other than the Agency Representative.

59. Staff Name

    First, Middle Initial, Last

60. Age
62. Phone Number
63. E-Mail
65. Emergency Contact/Relationship/Phone Number

    *In the event of any emergency while in our facilities, who should be contacted other than the Agency Representative.

69. 4. Companion Information
73. Companion Name

    First, Middle Initial, Last

74. Age
76. Phone Number
77. E-Mail
79. Emergency Contact/Relationship/Phone Number

    *In the event of any emergency while in our facilities, who should be contacted other than the Agency Representative.

83. In exchange for the opportunity to act as a Companion with the Maryland-National Capital Park and Planning Commission (M-NCPPC), the Department of Parks and Recreation, Prince George’s County, I agree to be bound by the following terms and conditions as evidenced by my signature below. The terms of this Agreement shall be binding on my heirs, executor, administrator and all members of my family.
85. Please read and check off*

    I agree to provide support as a companion to the participant identified on this form which may include; personal care, administration of medication, specific manual, verbal and/or visual accommodations prior to, during and/or after the activity as defined by M-NCPPC for programs, classes, events, drop-ins and/or memberships.

    1. Check here
87. Please read and check off*

    I acknowledge that there may be certain inherent risks related to the activity and understand that I may be subject to falls, slips, cuts, bruises as well as other unforeseen accidents. I agree to assume the risk of any injuries that I may incur, and to hold the Commission harmless for any such injuries, as a result of my participation in any activity as a Companion.

    1. Check here
89. Please read and check off*

    I acknowledge that my role as a companion is contingent upon my ability to accommodate the participant listed above within the program setting. This includes following the Code of Conduct and program rules. Disability Services staff have the sole discretion to determine what is to be in the best interest of M-NCPPC and the Department.

    1. Check here
91. Please read and check off*

    I understand that I may be required to submit to a Federal and State criminal background check if I am requesting to be a Companion in an M-NCPPC licensed program or where minors are present. Background checks may also be dependent upon the length and/or duration of the program(s). My approval as a Companion is contingent upon favorable results. (Background clearances from other agencies are non-transferable.)

    1. Check here
93. Please read and check off*

    I agree to follow the Park Rules and Regulations governing use of M-NCPPC Park and Recreation Facilities in Prince George’s County.

    1. Check here
95. Please read and check off*

    I understand and agree that this Companion agreement does not create an employee, volunteer, or agent relationship between the Agency/Representative/Companion and M-NCPPC.

    1. Check here
97. By selecting "I Agree" and my electronic signature below, I hereby certify that every statement I have made in this application is true and complete to the best of my knowledge. I understand that any false or incomplete answer may be grounds for disqualifying me for placement as a Companion and may be grounds for dismissing me after I have begun providing support.*

    1. I agree

    1. I disagree
99. Companion or Agency Representative Name*
101. Companion Signature*

     (A Parent/Guardian must sign if under age 18)

102. Date*
104. Agency Representative Signature*
105. Date*

109. Thank you for completing your online request. A representative with the M-NCPPC, Disability Services team will be in touch with you within five (5) business days.

111. For additional questions, please contact:
113. Northern Area Office
     Phone: 301-408-4350; E-Mail: Northern.Inclusion@pgparks.com
114. Central Area Office
     Phone: 301-249-7200; E-Mail: Central.Inclusion@pgparks.com
116. Southern Area Office
     Phone: 301-203-6000; E-Mail: Southern.Inclusion@pgparks.com
117. Special Programs Division Office
     Phone: 301-446-3400; E-Mail: Program.Access@pgparks.com
Leave This Blank:


119. 1. Receive an email copy of this form.
120. Email address

     This field is not part of the form submission.

121. Submit

* indicates a required field