Companion Agreement Form

Use this form to request a companion during participation in M-NCPPC, Department of Parks and Recreation, Prince George’s County programs and events.

1. Participant Information

Name(Required)

First Middle Initial Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

2. Program Information

Program/Event/Drop In/Membership

Start Date

End Date

Location

3. Complete this section ONLY if you are a Disability Agency Representative (otherwise skip to number 4)

Agency Name

Staff Member Completing Form

Title/Position

Agency Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

4. Companion Information

You may list up to 3 companions.

Name(Required)

First Middle Initial Last

Age(Required)

Phone

Emergency Contact/Relationship/ and Phone #

Signature(Required)

By signing this, I acknowledge and agree to the statements listed at the bottom of this form.

Date(Required)

Name

First Middle Initial Last

Age

Phone

Emergency Contact/Relationship/ and Phone #

Signature

By signing this, I acknowledge and agree to the statements listed at the bottom of this form.

Date

Name

First Midle Initial Last

Age

Phone

Emergency Contact/Relationship/ and Phone #

Signature

By signing this, I acknowledge and agree to the statements listed at the bottom of this form.

Date

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.(Required)

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.

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.

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.

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 nontransferable.

I agree to follow the Park Rules and Regulations governing use of M-NCPPC Park and Recreation Facilities in Prince George’s County. http://www.mncppc.org/236/Park-Rules-Regulation

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.

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.(Required)

Agree

Disagree

Participant Signature(Required)

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

Date

Parent/Guardian Signature

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

Date

Agency Representative Signature

Date

For additional questions, please contact:

Therapeutic Recreation Programs; 7833 Walker Drive, Suite 110 Greenbelt, MD 20770 301-408-4350; DisabilityServices@pgparks.com

Or contact:

Program Access Office; 2904 Enterprise Road Mitchellville, MD 20721 301-249-7200; Program.Access@pgparks.com

Companion Agreement Form