Kiosk PRCC Form - Faces & Voices of Recovery Data Hub

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Activity Check-In
Please select an option to provide your unique ID to check-in. This is either your primary email or primary phone number from your account.*
- Phone number
- Email address
Phone*
Email*
What activity or event are you here for today?*
- Participate in Recovery Activities
- Other
- Volunteer
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How long are you planning on volunteering today?*
Please enter a number from 0 to 24.
Type of Volunteer Activity*
- Front Desk
- Telephone Recovery Support
- Peer Support - Coaching
- Foodservice
- Community Service
- Special Event
- Group Facilitation
- Administrative Duties
- Other
Other Volunteer*
New Member Form
Guest Sign-Up
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Name*
First Last
Would you like to use your phone number, email address, or both as a unique code for checking in to activities?*
- Email
- Phone
- Both
Email*
Phone*
In the event we need to reach you, may we contact you at the number provided?*
- Yes
- No
Pronouns
How did you hear about our organization?*
- Friend/Family
- Treatment Provider
- Emergency Department
- Criminal Justice System
- Internet
- Healthcare Provide
- Cumberland County Jail
Race*
- Black or African American
- Asian
- Native Hawaiian/Pacific Islander
- Alaska Native
- White
- Native American
- Other
- Refused
Race, if Other:
Ethnicity*
- Hispanic or Latino
- Not Hispanic or Latino
- Refused
Gender Identity*
- Male
- Female
- Transgender
- Non-binary
- Other
- Refused
Gender, if Other:
Year of Birth
Do you identify as a person in recovery?*
- Yes
- No
- Prefer not to answer
Length of Recovery
U.S. Military Veteran?*
- Not a Veteran
- Veteran
- Refused
Are you also interested in signing up for peer services?
- Recovery Coaching
- Telephonic Recovery Supports
- Both Telephonic and In-person Recovery Services
* If you are interested in any peer services, a staff member will get in touch with you shortly.
Volunteer Sign-Up
Are you an existing participant who has used this kiosk to check in activities?*
- Yes
- No
Would you like to sign up as a volunteer with your phone number or your email?*
- Phone
- Email
Please enter your phone number:*
Please enter your email:*
Name*
First Last
Email*
Phone*
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What days are you available to volunteer each week?*
- Sunday
- Monday
- Tuesday
- Wednesday
- Thursday
- Friday
- Saturday
What time of the day are you generally able to volunteer? (Morning, Afternoon, Evening)*
- Morning
- Afternoon
- Evening
What are you most interested in doing as a volunteer? What are your skills and interests?