Project Inclusion Staff Registration Home 9 Project Inclusion Staff Registration If you are human, leave this field blank.Staff Information Project Inclusion Staff FormPlease complete the form by January 19, 2023. NOTE: You cannot save your partially completed form so please review the full form before starting to complete.Name *Name you prefer to be calledSchool *Please click to select optionsKecoughtan High SchoolPhoebus High SchoolHome PhoneCell Phone *Email *Address *CountryUnited States (US)United Kingdom (UK)CanadaAustralia---AfghanistanÅland IslandsAlbaniaAlgeriaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAmerican SamoaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelauBelizeBeninBermudaBhutanBoliviaBonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongo (Brazzaville)Congo (Kinshasa)Cook IslandsCosta RicaCroatiaCubaCuraÇaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqRepublic of IrelandIsle of ManIsraelItalyIvory CoastJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao S.A.R., ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorwayOmanPakistanPalestinian TerritoryPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalQatarReunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Martin (Dutch part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSan MarinoSão Tomé and PríncipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUruguayUzbekistanVanuatuVaticanVenezuelaVietnamWallis and FutunaWestern SaharaWestern SamoaYemenZambiaZimbabweCityStateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict Of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces (AA)Armed Forces (AE)Armed Forces (AP)American SamoaGuamNorthern Mariana IslandsPuerto RicoUS Minor Outlying IslandsUS Virgin IslandsZip codeT-Shirt Size *SmallMediumLargeX-LargeXX-LargeHome Language(s):Please check the boxes next to the following statements to demonstrate your understanding and commitment: *I will be present at the staff orientation meeting on January 12 at 4:00pm at the School Administration Center (1 Franklin St, Hampton, VA 23669)I will be present at the mandatory Staff Training beginning on February 12 at 5:30pmI will be present for the entire Project Inclusion program from February 9 – 12. Demographic Information Demographic InformationDate of birth *Please provide the following demographic information.*This information will be used to ensure that we have as diverse a community as possible. Only VCIC staff members see your responses*GenderReligious IdentityRacial/Ethnic Background (check all that apply) *African-American/Black/CaribbeanAmerican Indian/Native AmericanAsian/Asian-AmericanLatino(a)(x)/HispanicMiddle EasternWhite/European AmericanOther IdentityIs there any other information about your identity that you would like to share (i.e. ability status, languages spoken, national origin, etc.) Emergency ContactsEmergency Contact #1 Full Name *Emergency Contact #1 Phone *Emergency Contact #1 Relationship *Emergency Contact #2 Full Name *Emergency Contact #2 Phone *Emergency Contact #2 Relationship *Health History and Medical Release Health History and Medical Release This information is gathered to assist in identifying appropriate care for the participant. All medical information is confidential. Please make sure that you provide detailed and accurate information so that the on-site medical professional is aware of your needs. Depending on health conditions in February, VCIC may require masking and other mitigation practices. Do you have physical considerations that may restrict participation in program activities? *YesNoIf yes, please explainHave you been injured and needed medical treatment within the last year? *YesNoIf yes, please explainAre you presently undergoing professional counseling or therapy? *YesNoIf yes, please explainPlease list any allergies (food, medication, etc.)Describe reaction and management to the reaction belowAre you covered by family medical/hospital insurance? *YesNoIf YES, please share the following information:1. Insurance carrier/plan name2. Group # 3. Insurance company address4. Name of policy holder5. Policy holder's relationship to participant 6. Social security # of policy holder or insurance ID #Please list specific dietary restrictionsNo red meatNo poultryNo porkNo seafoodNo eggsNo dairyN/APlease list any additional specific dietary restrictions:Do you take medications on a routine basis? *Please list all medications (including over-the-counter or nonprescription drugs) taken routinely. Bring enough medication to last the entire duration of the program. Keep it in the original packaging/bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, dosage, and frequency of administration. YesNoWill you be taking any prescribed medication during the program? *YesNoIf YES, please provide the following information including the name of the medicine, the dosage, and times taken each day:Do you have any of the following medical conditions? (check all that apply)AllergiesAsthmaConvulsive DisordersDiabetes MellitusEpilepsyHeart ProblemHepatitis HIV Positive Muscular-Skeletal DisorderNeurological DisorderOtitis MediaSkin Infection Pulmonary Disorders Please list any other issues the medical staff should be aware of belowCOVID-19 Vaccination Status *We are requiring all staff to be fully vaccinated before the program. To be considered fully vaccinated, an individual must have received both a primary vaccine(s) and a booster at least two weeks before the program. Please indicate your current vaccine status. We will not share your vaccination status with anyone outside of the organization.I am fully vaccinatedI am partially vaccinated and plans to receive a booster by January 25If for religious reasons you cannot sign the statement below, contact the Virginia Center for Inclusive Communities for a legal waiver, which must be signed for attendance. *This health history is correct and complete as far as I know, and the person herein described has permission to engage in program activities except as noted. In the event of an accident or illness that requires emergency medical care, I hereby give permission to the attending (licensed) medical personnel to order such medical attention as may be deemed necessary for my health and safety. The medical information above is complete and accurate to the best of my knowledge.By checking this box, I acknowledge and agree to the above section.I cannot sign this agreement and will contact VCIC for a legal waiverSignature *Reset SignatureSignature is required.Date *AgreementsAfter Project Inclusion, a contact list is given to participants and staff. Please initial one choice below: *I do grant permission for my address, phone number, and email address to be distributedI do NOT grant permission for my address, phone number, and email address to be distributedPlease read the following information and select one box below: *I understand that I, alone or with other participants and/or Virginia Center for Inclusive Communities (“VCIC”) staff, volunteers, or representatives, may be photographed, recorded on film, audio tape, videocassette, or other visual and sound, computerized, telephonic, voice-mail or tape media (“photographs and/or sound/image recordings”) by VCIC and/or others approved by VCIC. I hereby consent to the foregoing and grant permission, without reservation, to VCIC and/or those approved by VCIC to generate, prepare, advertise, describe, and/or publicize VCIC and its work, good will, public education, and/or fundraising activities, disseminate, otherwise use and comment upon the photographs and/or sound/image recordings as they may determine, without review by me/my child and without financial or other obligation of any nature to me. I consent that I may be identified by name, age, and place of residence or otherwise, as VCIC and/or those approved by VCIC may determine. I release VCIC, its officers, volunteers, agents, employees, licensees, and assigns from all claims that I/my child may have, or might have, for any cause of action arising out of the taking and/or use of the photographs and/or sound/image recordings as set forth herein. This consent and release shall continue in effect, without a limitation of time. I understand that a full group picture will be taken by VCIC and provided to all program participants no matter which box is checked below. I do consent and agree to the photo release terms above I do NOT consent and agree to the photo release terms above Project Inclusion Code of Ethics Staff members will maintain confidentiality at and after the Project Inclusion experience (except for mandatory reporting, such as abuse or when individual is a danger to self or others). Staff members will exhibit language that is consistent with the Project Inclusion mission (no disrespectful comments related to ability, body type, class, gender, race, religion, sexual orientation, etc.). Staff members will obey the law in all aspects of interaction with the program, participants, staff members, and VCIC staff. Staff members will not abuse participants in any way, including (but not limited to) the following: Physical abuse: hitting, spanking, shaking, slapping, unnecessary restraints Verbal abuse: degrading, threatening, cursing Sexual abuse: inappropriate touching, exposing oneself, sexually oriented conversations Mental abuse: shaming, humiliation, cruelty Neglect: withholding food, water, shelter Staff members will have no physical (sexual, romantic, inappropriate touching) relationships with other volunteers at the Project Inclusion program or with participants at or after the Project Inclusion program. Staff members will avoid any favoritism and will treat everyone equally and respectfully at all times. Staff members will adhere to uniform standards of displaying affection as outlined by VCIC. Staff members will adhere to uniform standards of appropriate verbal interactions as outlined by VCIC. Staff members will not be alone with minors in meeting spaces. There should be staff members of different genders present when you are meeting with an individual minor. Staff members will model respect for program facilities. Staff members will not use or be under the influence of alcohol or illegal drugs in the presence of participants. Staff members will not have sexually oriented materials, including printed or online pornography, on the program site. Staff members will not engage in inappropriate electronic communication with participants, during or after the program. Staff members may maintain relationships with the participants after the Project Inclusion program if the outreach is student-initiated. If a student reaches out, staff members must notify VCIC immediately and a VCIC staff member should be copied on all future correspondence. All communication should be in support of positive, supportive, and healthy mentoring relationships. Staff members will abide by the decisions of the co-directors and Virginia Center for Inclusive Communities before, during, and after the program. Staff members are prohibited from making use of or reproducing Project Inclusion curricula or ancillary material for any purpose other than rendering service to the Virginia Center for Inclusive Communities. Consent for Code of Ethics *By checking this box, I am agreeing to the Project Inclusion Staff Code of Ethics stated aboveName *Date *Signature *Reset SignatureSignature is required.Submit