PENINSULA DIVERSITY DIALOGUE DAY SCHOOL REGISTRATION FORM

*This form must be received by VCIC by December 16, 2020*
Please write out the full name of the school
Please include area code
To reach you on the day of the program (include your area code)

PLEASE SHARE THE FULL NAMES OF THE STUDENTS YOU WOULD LIKE TO REGISTER:

All student names and completed permission forms are required prior to the program. If unable to fill in now, contact Paula L. Bazemore prior to December 16 (pbazemore@inclusiveVA.org). If you don't plan to fill all 8 spots, type N/A.

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