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
Your information is completely confidential and is only viewed by authorized PRCC staff. Demographic information is reported only in aggregate and is never connected to individual participants when shared with funders. Providing this information helps PRCC secure funding that keeps our services free and available to all.
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
Race, if Other:
Ethnicity*
- Hispanic or Latino
- Not Hispanic or Latino
Gender Identity*
- Male
- Female
- Transgender
- Non-binary
- Other
Gender, if Other:
Year of Birth*
Do you identify as a person in recovery?*
- Yes
- No
Length of Recovery
U.S. Military Veteran?*
- Not a Veteran
- Veteran
How many people are in your household?*
What is your total annual household income before taxes?*
- No income
- Under $10,000
- Between $10,001 and $20,000
- Between $20,001 and $30,000
- Between $30,001 and $40,000
- Between $40,001 and $50,000
- Between $50,001 and $60,000
- Between $60,001 and $70,000
- Between $70,001 and $80,000
- Between $80,001 and $100,000
- Above $100,000
- Other
What is your current housing situation?*
- Housed
- Unhoused
- Shelter
- Recovery Residence
- Residential Treatment
- Institution
- Halfway House
- Other
Housing Situation, if Other:
Are you interested in signing up to receive these services?
- Recovery Coaching
- Telephonic Recovery Supports
- Both Telephonic and In-person Recovery Services
* If you are interested in receiving any of these services, a staff member will get in touch with you shortly.
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Are you interested in information about Nicotine Use/Quitting?*
- Yes
- No
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?