Connections Summit Permission Form & Participant Agreement

Please complete the form by June 22, 2022.

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

Student Information

Participant's Name *

Name student prefers to be called

Student date of birth *

Parent/Guardian Information

Parent/Guardian Full Name *

Parent/Guardian Email *

Daytime Phone *

Cell Phone *

Language spoken at home

Emergency Contacts

Emergency Contact 1 Full Name *

Emergency Contact 1 Phone *

Relationship to Participant *

Emergency Contact 2 Full Name *

Emergency Contact 2 Phone *

Relationship to Participant *

Medical & Health Information

Does this participant have any medical limitations that will restrict participation in program activities? *

Yes

No

If yes, please explain

Please list specific dietary restrictions for the student. *

Please list any allergies the student may have. *

Does this participant take medications on a routine basis? *

Yes

No

Will the applicant be taking any prescribed medication during the program? *

Yes

No

If yes, please provide the following information including the name of the medicine, the dosage, and times taken each day:

I give permission for the Connections staff to administer the following over-the-counter medications to my child if requested (please check all that apply):

Anti-Itch Spray

Benadryl

Motrin (Ibuprofen)

Antibiotic Cream

Maalox

Pepto-Bismol

Tylenol

COVID-19 Vaccination Status *

We are requiring all participants 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. Please indicate the participant's current vaccine status. We will not share the participant's vaccination status with anyone outside of the organization. If the participant does not plan to be fully vaccinated before the program, a VCIC staff member may reach out to discuss further options.

The participant is fully vaccinated

The participant is partially vaccinated and plan to receive my booster by July 11

The participant does not plan to be fully vaccinated by the date of the program

The participant would prefer not to answer at this time

The participant has a medical exemption

Communication and Mailing

This section should be filled out by a parent or guardian.

Mailing Address *

Apt, suite, etc.

Country

City

State

Zip code

To help us send reminders and communicate quickly with participants, VCIC is establishing an optional text messaging group through Remind. If you would like to sign up the participant, please provide the best cell phone number to reach them.

By checking this box, I agree to have my child/the child in my care receive text messages from VCIC staff regarding the Connections Summit program. Standard messaging rates may apply.

Phone Number to Receive Texts

Participant Agreement

This section should be filled out by the participant.

1. 1. I agree to be present for all three days of the Connections Summit sessions, from beginning to end.
  2. I will be on time for all Connections Summit sessions.
  3. I will remain within the Connections Summit site boundaries at all times unless accompanied by a staff member in an emergency.
  4. I will not bring any weapons, laser pointers, or other prohibited material to the Connections Summit.
  5. I will not bring or use any drugs at the program except medication detailed in the medical information section of this application.
  6. I will turn in all medication to the designated person at Connections Summit in original containers upon arrival.
  7. I will abide by mask requirements set by the program directors.
  8. I will not engage in sexual activity at Connections Summit.
  9. I will pay for any facility damage for which I am responsible.
  10. I will wear my nametag at all times.
  11. I understand that cell phone usage will be prohibited during program sessions. The presence or use of cell phones during program sessions will result in the phone being confiscated and held until the end of the program day.
  12. I understand that violating any of these rules can result in immediate dismissal from Connections Summit at the discretion of a Co-Director.
  13. If I am dismissed, my parent/guardian will be called to pick me up from the facility.
  14. To the best of my ability, I will join in the spirit of Connections Summit at all times.

Acknowledgment *

By checking this box, I, the participant, acknowledge and agree to the above section.

Participant Name *

Participant's Signature *

Reset Signature

Signature is required.

Parent/Guardian Consent

This section should be filled out by the participant's parent/guardian.

After Connections, a contact list is distributed to all participants and staff. Please check one box below: *

I do grant permission for my/ my child’s address, phone number, and email address to be distributed to other Connections participants and staff

I do NOT grant permission for my/ my child’s address, phone number, and email address to be distributed to other Connections participants and staff

Social Media Permissions *

All Connections staff will go through a background check, and are required to ensure that interactions with students are healthy and supportive, both at and after the program. Except in emergencies, no staff member should initiate contact with a minor. Occasionally, students will want to reach out to Connections staff members after the program in mentoring relationships. Please check a box below:

I give staff permission to stay in touch with my child electronically (including on social media) after the program so long as that communication is initiated by my child.

I do NOT give staff permission to stay in touch with my child electronically) including on social media) after the program

Photo/Video Permissions *

I understand that I/my child, 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 Inclusive Communities 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/my child. I consent that I/my child 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. I understand that a full group picture will be taken by VCIC and provided to all Connections participants no matter which box is checked below. This consent and release shall continue in effect, without a limitation of time. Please check one box below:

I do consent and agree to the photo release terms mentioned above

I do NOT consent and agree to the photo release terms mentioned above

Parent/Guardian Agreement

I give permission for my child/the child in my care to participate in Connections Summit sponsored by the Virginia Center for Inclusive Communities on July 26, 27, and 28, 2022. I understand that Connections Summit is a human relations program that deals with mature subject matters possibly including stereotypes, prejudice, communication, racism, sexism, religious bias, etc.
The health history provided is correct and complete and accurate to the best of my knowledge, 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 medical point person to order such medical attention as may be deemed necessary for the health and safety of my child (or the person of whom I am legal guardian). In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by the Director to secure and administer treatment, including hospitalization, for the person named above.
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/the child in my care. 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.
If the Connections director must send my child home for any reason, I agree to pick up my child within two hours of the director's call (unless other arrangements are made with the director). I understand that I will be responsible for all costs associated with such transportation.
If my child's medical information should change prior to the program, I will notify the Virginia Center for Inclusive Communities of any new conditions, medications, limitations, etc. I understand that my child will be asked to abide by mask requirements set forth by Connections co-directors.
I understand that student participants are asked to complete an evaluation that assesses their views on human relations issues and the Connections Summit program. I give permission for my child/the child in my care to complete such forms.