000-TEST | Virginia Center for Inclusive Communities

2024 Harold M. Marsh, Sr. Connections Institute School/Team Interest Form

Please provide the following information indicating your interest in sending a team to the 2024 Connections Institute. Note that filling out this form does not constitute a complete registration.

Institution Name *

Phone *

Please include your area code

Contact Person *

This should be the person that will coordinate and facilitate the information between VCIC and your students. Your role will include: recruiting students, collecting applications, passing along all communications from VCIC, and coordinating your students' attendance.

Contact Email *

Street Address *

Country

City

State

Zip code

Please check all that apply:

I am interested in registering my institution for Connections 2024. Please reach out to me directly to schedule a meeting to discuss details.

I would like to register my school for Connections 2024. A $250 deposit is in process to reserve my group’s space. The remaining $1,750 balance will be sent by March 15.

My institution would like to receive three Connections follow-up workshops during the 2024-2025 school year to support action plans. An additional $375 will be sent by March 15.

[Placement is granted on a first-come, first-served basis. We must receive payment to hold your school’s space.]

Entity Responsible for Payment *

Payment Entity Contact Name

If different from above

Payment Entity Address

If different from institution street address above

Country

City

State

Zip code

Payment Entity Contact Phone

If different from above

Payment Entity Contact Email

If different from above