Family Safety Planning Toolkit Request Form
Prefix:
Please select...
Mr.
Ms.
Mrs.
Mx.
Chief Judge
Dr.
Hon.
Judge
Magistrate
Prof.
Senior Judge
First Name:
Last Name:
Email Address:
Email Label:
Personal
Work
Other
Primary Address
Company/Organization:
Address 1:
Address 2:
City:
State:
Please select...
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
ZIP Code:
Website:
Phone Contact (s)
(XXX-XXX-XXXX)
Home Phone:
Cell Phone:
Work Phone:
Primary Phone Contact:
Home
Cell
Work
What kind of organization or employer do you work for?
Please select...
legal services provider
law firm
Consulate
Youth Organization
Community Center
Social Work
Government
News/Media
Church
ESOL Teacher
Guidance Counselor
School -Other
Listservs
Healthcare Provider
Other
If Other, please specify:
Please enter all states where you are licensed to practice (including Maryland) and the year and bar number.
State Licensed
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Puerto Rico
Virgin Island
Northern Mariana Islands
Guam
American Samoa
Palau
Year Admitted
Please select...
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Bar Number
Status
Please select...
Good Standing
Not In Good Standing
Please check to acknowledge:
I understand that this toolkit is provided to me as a resource to assist my efforts to help immigrant families. I promise to conduct my own independent review of the documents and current laws before using it to provide family safety planning assistance or advice. I also promise that I will not share the toolkit in its entirety with other persons or organizations without written permission from PBRC.
Please check to acknowledge:
I understand that as a non-attorney, I can help families collect important documents, encourage parents to create a plan, interpret or translate for parents, and share legal information with families, but I cannot give families advice about how that legal information will apply to their situation as that would be committing the unauthorized practice of law. I promise to not use this toolkit to commit the unauthorized practice of law. I also promise that I will not share the toolkit in its entirety with other persons or organizations without written permission from PBRC.
Would you like to receive emails from PBRC about events to help immigrants in removal proceedings?
Yes
No
E-Bulletin
Yes, I would like to receive PBRC's E-Bulletin, a bi-weekly email about pro bono opportunities in MD
Need help? Contact PBRC!