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2. Fill out form below. Read all sections and sign to submit.
4. Name*
5. Email Address*
7. Address*
9. City*
10. State*
11. Zip Code*
13. Phone Number*
14. Cell Number
16. Preferred Method of Contact*

    1. Email
    2. Phone
    3. Cell
17. Are you 18 years of age or older?*

    1. Yes
    2. No
19. First Aid/CPR Certification?*

    1. Yes
    2. No
20. Expiration Date:
22. Emergency Contact Information:
24. Name*
25. Relationship*
26. Phone*

30. Volunteer Agreement.

    I understand that I am offering my services to the City of Roanoke without compensation. Once I become a City of Roanoke volunteer, I agree to abide by all City rules, regulations and policies, either published or in effect by custom and usage, and all rules, regulations and laws of the State of Virginia as may be required by City and State Statutes.

32. Initials *

    Initial to acknowledge the above statement.

36. Release from Liability 

    1. Voluntary Participation: I acknowledge that I have voluntarily applied to serve as a volunteer for the City of Roanoke through the Municipal Volunteer Program (MVP), in which volunteers assist city departments. I understand as a volunteer that I will not be paid for my services, and should I be injured while performing duties on behalf of the City, the city provides insurance which offers limited medical benefits. This insurance has a $25,000 limit, is strictly excess and will only respond to expenses after all other insurance is exhausted.

    2. Release: In consideration of the opportunity afforded me to serve as a volunteer for the City of Roanoke through the Municipal Volunteer Program (MVP), I hereby agree that I, my assignees, heirs, guardians, and legal representatives, will not make a claim against the City of Roanoke, or their officers or directors collectively or individually, or the equipment that is used by the City, or any of the volunteer workers, for the injury or death to me or damage to my property, however caused, arising from my participation in the Municipal Volunteer Program (MVP). Without limiting the generality of the foregoing, I hereby waive and release any rights, actions, or causes of action resulting from personal injury or death to me, or damage to my property, sustained in connection with my participation in the Municipal Volunteer Program (MVP). I further consent to the unrestricted use by City of Roanoke’s Municipal Volunteer Program (MVP) and/or person(s) authorized by them of any photographs, recordings, interviews, videotapes, motion pictures or similar visual recording of me.

38. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
40. Electronic Signature
Leave This Blank:


42. 1. Receive an email copy of this form.
43. Email address

    This field is not part of the form submission.

44. Submit

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