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Companion Agreement Form

  1. 1. I am requesting to be a Companion for the following Participant:
  2. First, Middle Initial, Last

  3. 2. Activity Information:
  4. 3. Disability Agency Representative*
  5. 3a.
  6. First, Middle Initial, Last

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

  8. First, Middle Initial, Last

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

  10. First, Middle Initial, Last

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

  12. 4. Companion Information
  13. First, Middle Initial, Last

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

  15. 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.
  16. 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.
  17. 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.
  18. 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.
  19. 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.)
  20. 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.
  21. 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.
  22. 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.*
  23. (A Parent/Guardian must sign if under age 18)

  24. For additional questions, please contact:
  25. Northern Area Office
    Phone: 301-408-4350; E-Mail: Northern.Inclusion@pgparks.com
  26. Central Area Office
    Phone: 301-249-7200; E-Mail: Central.Inclusion@pgparks.com
  27. Southern Area Office
    Phone: 301-203-6000; E-Mail: Southern.Inclusion@pgparks.com
  28. Special Programs Division Office
    Phone: 301-446-3400; E-Mail: Program.Access@pgparks.com
  29. Leave This Blank:

  30. This field is not part of the form submission.