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2. Name:
4. Address 1
6. Address 2
8. City
9. State
10. Zip
12. Phone Number:
13. Email:
15. Availability to serve outside your neighborhood:

    1. Yes
    2. No
16. Availability:

    1. A.M.
    2. P.M.
    3. Both A.M. and P.M.
18. As a volunteer of the City of Rockville, I understand and accept, agree and hold harmless as follows: That I am volunteering my time and resources to the City of Rockville, and that I will not be compensated nor put on payroll. Certain injuries resulting from my volunteer work may not qualify for benefits under Maryland Workers Compensation law. I hereby agree to release and indemnify the Mayor and Council of the City of Rockville and all its agents, officers and employees, from any and all claims for injuries or loss of any person or property which may arise out of or result from the participation in the volunteer work I perform. In accepting the inherent risk of participating in this volunteer work, I recognize the consequences may include the possibility of personal injury and I agree to not hold the City responsible. I agree to sign this form prior to the commencement of my volunteer activities. I have read and fully understand the above statements and agree by completing and submitting this form.
20. 1. I Agree
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22. 1. Receive an email copy of this form.
23. Email address

    This field is not part of the form submission.

24. Submit

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