Diversity Dialogue Day – Student Registration for March 26 | Virginia Center for Inclusive Communities

2021 DIVERSITY DIALOGUE DAY STUDENT INFORMATION & PERMISSION FORM

Student’s Full Name (First, Middle, Last) *

Name Student Prefers to be called *

School *

Please type out full name of school

School Contact Email

email address of school contact / educator that asked you to submit this form

Parent/Guardian Name *

Parent/Guardian Email *

Parent/Guardian Phone *

Student Email *

Does your student need additional support for engaging by video, with virtual dialogue or written reflection in English? *

(Note that VCIC will do our best to meet all requests.)

Yes

If yes, please explain

Agreements

I give permission for my child to participate in the virtual 2021 Diversity Dialogue Day (DDD) sponsored by the Virginia Center for Inclusive Communities from 10:00 am – 2:00 pm on March 26, I understand that DDD is a human relations program that deals with mature subject matters possibly including stereotypes, prejudice, communication, racism, sexism, religious bias, etc.
I understand that although the program sponsor has taken precautions to provide proper organization, supervision, and instruction for each activity, it is impossible for the sponsor to guarantee absolute safety. I also understand that each participant shares the responsibility for safety during all activities and I assume that responsibility for my child. I waive any claim that may arise against the Board of Directors of the sponsor, and/or its employees, agents, volunteers, or lessors including those claims which may arise from the negligence of the sponsor, their Board of Directors; and/or its employees, agents, lessors or volunteers.
I understand that student participants are asked to complete an online evaluation that assesses their views on human relations issues and the DDD program. I give permission for my child to complete such forms.
I give permission for my child to be photographed or videoed by sponsors and/or others approved by sponsors at Diversity Dialogue Day.

Parent/Guardian Printed Name *

Parent/Guardian Signature *

Sign on the line with mouse cursor or with your finger on a touchscreen.

Signature is required.

Date *