MONTGOMERY COLLEGE



MONTGOMERY COLLEGE

GENERAL VOLUNTEER REGISTRATION FORM

Completion of this form is required by all volunteers. The College provides medical benefits for volunteers injured while performing duties on behalf of the College as directed by the supervisor, equal to medical benefits as required to be provided under the Workers’ Compensation Law of the State of Maryland. Please complete this form as accurately as possible. Be assured that this information is confidential and for use only by Human Resources and Strategic Talent Management.

As a condition of volunteering at Montgomery College the completion of a background check might be required.

Please Type or Print Clearly

Name:_______________________ Age (if under 18 years of age)________

Street Address: ________________________________________ Apt. #:________

City: ________________________ State:_________ Zip Code: _________________

Email Address (Required)_______________________________________________________

Phone Number (Required)___________________________________________

Assignment Begin and End Dates (must be completed by the supervisor)_____________

Work Schedule_______________________________________________________

I hereby state that the above information is correct as of this date.

Volunteer’s Signature: _______________________________ Date: ______________

Supervisor’s Signature _______________________________ Date: _______________

Print first and last name of Supervisor _________________________Phone No.: _________

Supervisor’s email address ____________________________________________________

Department/Division ___________________________

(Please note, the supervisor information must be completed before this form is sent to HRSTM

Return to: Lori Stegeman, HRSTM, Montgomery College

9221 Corporate Blvd.

Rockville, MD 20850

PH: 240-567-7301 FAX: 240-567-4431, lori.stegeman@montgomerycollege.edu

If you will be driving on behalf of Montgomery College, you must also submit a current copy of your driving record from the MVA.

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