DDD Lynchburg – Schools Registration Form | Virginia Center for Inclusive Communities

LYNCHBURG DIVERSITY DIALOGUE DAY SCHOOL REGISTRATION FORM

*This form must be received by VCIC by February 14, 2023*

School Name *

Please write out the full name of the school

Principal Name *

Street Address *

Country

City

State

Zip code

School Phone *

Please include area code

Fax

Advisor Name *

Advisor Title *

Advisor Phone *

To reach you on the day of the program (include your area code)

Ext.

Email *

Would you like to be included in an advisor networking list? *

Yes

Attending advisor dietary restrictions (please be specific):

Due to parking limitations, schools are encouraged to drop off and pick up their participants. Will you need a designated parking space for the day? *

Yes

If YES, please note the quantity and type(s) of vehicle(s):

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 Alejandro prior to February 14, 2023 ([email protected]) If you don't plan to fill all 15 spots, type N/A.

1. *

1) Grade *

1) Gender *

1) Race *

2. *

2) Grade *

2) Gender *

2) Race *

3. *

3) Grade *

3) Gender *

3) Race *

4. *

4) Grade *

4) Gender *

4) Race *

5. *

5) Grade *

5) Gender *

5) Race *

6. *

6) Grade *

6) Gender *

6) Race *

7. *

7) Grade *

7) Gender *

7) Race *

8. *

8) Grade *

8) Gender *

8) Race *

9. *

9) Grade *

9) Gender *

9) Race *

10. *

10) Grade *

10) Gender *

10) Race *

11. *

11) Grade *

11) Gender *

11) Race *

12. *

12) Grade *

12) Gender *

12) Race *

13. *

13) Grade *

13) Gender *

13) Race *

14. *

14) Grade *

14) Gender *

14) Race *

15. *

15) Grade *

15) Gender *

15) Race *