County Captain Activity Form

Submit for each activity you’re involved in as a PBCC County Captain!

Name(Required)

First Last

County(Required)

Email(Required)

Phone(Required)

Activity/Event Name(Required)

Name of Activity/Event Location(Required)

Address

Street Address Address Line 2 City State / Province / Region PA County

Date of Activity/Event(Required)

Start Time(Required)

End Time(Required)

Total Hours(Required)

Type of Activity(Required)

Grassroot Partner Event

Check Presentation

Health Fair/Community Event

Research Grant Check Presentation

Photo Exhibit Reception

Legislative Event/Initiative

Friends Like Me Drive

PBCC Event

Other

Please describe

Please share your overall experience, including highlights, challenges, and any additional feedback.

Is there anything you’d like the PBCC team to know from your experience—memorable conversations or interactions, questions raised, or ideas for the future?

Upload Your Photos!

We love showcasing our incredible County Captains and the amazing work they’re doing across our website, social media, and beyond!

Drop files here or

Max. file size: 50 MB.

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