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2. First Name*
3. Last Name*
5. Address 1
7. City
8. State
9. Zip
11. Email*
12. Phone Number
14. Available Start Date
    Available Start Date
16. School
18. Current GPA*
    2.5 minimum
19. Grade Level*

    1. Grade 10
    2. Grade 11
    3. Grade 12
21. Please describe your leadership and/or volunteer experience at school or within the community (250-word maximum).*
23. Please explain what interests you about this program (250-word maximum). *
25. Please provide the name of at least one adult endorser (teacher or school counselor only) and his/her work email address and phone number.*
27. Would you be able to serve an entire term (October 2023 — June 2024) as a HRC Student Ambassador? *

    1. Yes
    2. No
29. Would you be able to participate in any monthly HRC meetings held at Rockville City Hall or virtually? (HRC meetings are scheduled on the 4th Wednesday of every month from 7:30- 9 p.m.)*

    1. Yes
    2. No
    3. Maybe
31. If your response to the question above is "Maybe", please explain why.
33. If your response to the question above is "Yes", what percentage of meetings would you be able to attend? (Please estimate.)

    1. 25%
    2. 50%
    3. 75%
    4. 100%
35. Would you be able to participate in any periodic HRC teleconferences? (Note: Teleconferences are typically held during weekdays between 7-9 p.m.)*

    1. Yes
    2. No
    3. Maybe
37. If your response to the question above is "Maybe", please explain why.
39. Parent or legal guardian's name*
41. Parent or guardian's email*
42. Parent or guardian's phone*
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44. 1. Receive an email copy of this form.
45. Email address

    This field is not part of the form submission.

46. Submit

* indicates a required field