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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