2022 Hampton Roads Connections Student Application

Please complete the form by May 22, 2022.

In order for selected students to attend the program, they must also have a parent or guardian sign a permission form (in addition to signature below). Permission forms will be sent out after the information form is received, and due by June 15.

NOTE: You cannot save your partially completed form so please review the full form before starting to complete.

Student Information

Please complete the following section with the student's name and contact information

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

Name Student Prefers to be called

Address *

Country

City

State

Zip code

Email *

Phone *

Grade in Fall of 2022 *

Grade 10 | Sophomore

Grade 11 | Junior

Grade 12 | Senior

School that you will be attending in the Fall of 2022 *

Please write the full school name (ex: Virginia High School) without abbreviation (ex: VHS)

Are any particular accommodations needed for the student to be able to join? *

Accommodation requests will only be used to help VCIC plan a program that is as accessible as possible

Yes

No

If yes, please explain

Please check the box that best reflects your current transportation plan *

Your selection does not need to be final at this point, and you can change your mind at any time.

I may need transportation from a central location.

I plan to use my own form of transportation. Options could include driving myself, being dropped off, or taking public transportation.

Please provide the following demographic information.

*This information will be used to ensure that we have as diverse a community as possible.*

Gender

Religious Identity

Is there any other information about your identity that you would like to share (i.e. ability status, languages spoken, national origin, etc.)

Short Answer Questions

Please respond to the following three questions using the text box below (no more than 500 words total). This is not a graded assignment, so please write in a way that is most comfortable to you. We are wanting to learn about you and will not be judging responses based on English proficiency or spelling and grammar. Your submission must be your own original content and has to be created specifically for your Connections application form.

Explain why you are interested in attending Connections, and what you hope to gain from the program.
What are you currently involved in at school or in your community?
From your perspective, what are the biggest issues facing your school or community?

Short Response Area

500 Word Limit

Please use this space to share the name of the school, organization, or individual who referred you, or to describe your answer of 'other.' *

Acknowledgment *

By checking this box, I verify that I have not attended a past Connections Institution or Project Inclusion retreat.

By checking this box, I acknowledge that I am required to be fully vaccinated and will need to submit verification before I am able to attend Connections.

By checking this box, I express my commitment to attend VCIC’s Connections Summit if selected.

Applicant Signature *

Reset Signature

Signature is required.

Parent / Guardian Consent

Parent / Guardian Name *

Parent / Guardian Phone *

Parent / Guardian Email *