LYNCHBURG DIVERSITY DIALOGUE DAY SCHOOL REGISTRATION FORM

*This form must be received by VCIC by February 7, 2022*
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)
As we will be using breakout rooms during DDD, each student will need access DDD from an individual device. Is it also recommended for students to use headphones
If someone else other than main contact on this form plans to attend, please name that individual in the blank space and provide their email address.

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 Emma Cox prior to February 7 (ecox@inclusiveVA.org). If you don't plan to fill all 15 spots, type N/A.

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